​SURGICAL ONCOLOGY "QUICK & DIRTY"
 

These are the exact notes I created and used to dominate the written and oral boards for general surgery. This is not meant to be a comprehensive review (that’s what the 100+ page NCCN guidelines are for). Instead, I only provide information that is highly relevant and practical in terms of branch points in the treatment algorithms (i.e. I think it’s clinically useless to know the full TNM staging in most cancer types as treatment may be based simply on T or N stage. Also, I will not write out the description of stage IV disease as it always means metastatic disease).

The field of oncology is one that evolves rapidly and is highly tailored to each specific patient (this is good for patients but not so good if you’re the doctor trying to learn the treatment algorithms – especially if you are not specializing in oncology); therefore, these are general guidelines that will help you understand the big picture and do well in testing scenarios (i.e. when getting pimped on rounds or when taking the oral boards). Please refer to NCCN guidelines when treating actual patients.

Again, the goal is to learn as much as possible with the least amount of energy expenditure (the 80/20 rule – learn 80% of the total knowledge while using only 20% of the effort required to learn it all). Think of these simplified algorithms like text messages – they get the point across but you wouldn’t want to show them to your English teacher (they would smack you for your poor grammar!). Similarly, these outlines should not be used as your primary source of information on your surgical oncology rotation, but rather should help you dominate the ABSITE and boards.​

BREAST CANCER
Staging
T1: <2cm
T2: 2-5cm
T3: >5cm
T4: chest wall invasion
N1: ipsilateral mobile axillary LN
N2: ipsilateral fixed axillary LN or internal mammary LN
N3: any clavicular LN or axillary + internal mammary LN
Stage I: T1 only
Stage II:  T2-3 or T0-2,N1
Stage III: Any N2 or T3-4,N1

Preoperative workup
Diagnostic mammogram
Core needle biopsy (with ER/PR/Her2 receptor testing)
CXR, LFTs
If +LN or >5cm tumor, add PET CT Chest /Abdomen /Pelvis & MRI brain
If young patient, add MRI breast and BRCA workup
BRCA + pts should all get MRI breast screening

Treatment
DCIS: Lumpectomy* → Adjuvant RT + Endocrine therapy
-Goal  2mm negative margins

Invasive cancer with negative LN & no chest wall invasion: Lumpectomy + SLNB
-If negative SLN → Endocrine therapy + RT
-If + SLN**→ AxLND →Chemo + Endocrine therapy → RT

Invasive cancer with + LN or chest wall invasion:
-Neoadj chemo → Lumpectomy/Mastectomy + AxLND → Endocrine therapy + RT

* If lumpectomy contraindicated, do mastectomy + SLNB
** According to Z011, T1-2 cancer with 1-2 + SLN can be treated like SLN negative patients if getting adjuvant RT.

Misc
-Contraindications to breast conservation therapy (BCT): If creates poor cosmesis, multicentric disease, T4, prior RT, collagen vascular disease, pregnant (1st or 2nd trimester)
-Indications for adjuvant chemo: +LN, >1 cm tumor (although can omit chemo in >1 cm tumor if ER+ & HER2 neg with neg oncotype testing), >5mm tumor if triple negative or HER2+
-Indications for RT after mastectomy: Invasion of skin/chest wall/pec fascia, ≥4LN+, ≥5cm tumor
-Endocrine therapy: tamoxifen if pre-menopausal, aromatase inhibitor if post-meonpausal (If ER or PR neg, benefits of these meds uncertain) for 5 years. If HER2 +, add traztuzamab for 1 year (get echo first to rule out CHF).
-Inflammatory breast cancer: Need punch biopsy to diagnose. Then treat like invasive cancer with chest wall invasion (although would need mastectomy not lumpectomy, given extensive skin involvement)
-Occult breast cancer (+axillary LN with normal mammogram): Get MRI breast. If MRI neg, treat like inflammatory breast cancer.
-If HER2+ & >2cm, do not use standard algorithm above, instead give neoadjuvant pertuzamab with traztuzamab, then proceed with surgery & RT.
-Standard chemo regimen: AC followed by T (adriamycin, cyclophos, then taxol)

Follow up
Q6 month exam

Q12 month mammogram

THYROID CANCER

Staging
TNM staging varies by cancer type and by age
Useful to know that for papillary & follicular carcinoma in patients <45 years old, everything without mets is T1, presence of mets is T2.

Preoperative workup
Ultrasound is first step
FNA if >1cm 
Check TSH  and free T4
 
Treatment
Papillary thyroid cancer
Total thyroidectomy, (with CLND if clinically +LN on ultrasound or exam) with post op radioactive iodine
If low risk (<45 years old, <1cm nodule, no +LN, no h/o radiation) can consider lobectomy and omit radioactive iodine
Post op levothyroxine for TSH suppression

Follicular thyroid cancer
Usually going to present as a thyroid nodule with a FNA that shows a Follicular Neoplasm
Diagnostic thyroid lobectomy first
If final path shows invasive cancer, do completion total thyroidectomy (with CLND if clinically +LN on ultrasound or exam) with post op radioactive iodine.
Can consider stopping at lobectomy if low risk (patient age < 45 years, <1cm in size, no extrathyroidal extension)
Post op levothyroxine for TSH suppression
Hurthle cell variant requires total thyroidectomy and is unresponsive to radioactive iodine

Medullary thyroid cancer
Check metanephrine levels to rule out pheo
If + metanephrines, get CT abdomen /pelvis and do adrenalectomy first for pheo
Check PTH & calcium to look for concurrent parathyroid disease which runs with MEN
Preop thyrogobulin and calcitonin levels
All patients get genetics work up
MEN 2A - surgery by age 5
MEN 2B - surgery during first year of life or at time of diagnosis (very rare)
Total thyroidectomy + CLND for all (add modified radical neck dissection if ultrasound shows +LN in the lateral neck)
No radioactive iodine
Follow calcitonin, thyroglobulin and CEA levels to look for recurrence
If post op calcitonin elevated, give external radiation 
Auto dominant - screen patient's children

Misc
-Ok to use Synthryoid if you plan on using Thyrogen stimulation for RAI
-Alternatively, can do Synthryoid withdrawl for six weeks and then give RAI
-Chemo/RT only occasionally used for any unresectable, locally invasive or recurrent disease or for mets
-Neck lymph node dissection levels: I submental, II superior jugular, III mid jugular, IV inferior jugular, V transverse cervical, VI pre/paratracheal, VII behind the sternum
-Mod Rad ND - all LN tissue from mandible to clavicle, anterior trapezius to lateral sternohyoid, open carotid sheath; spare IJ, CN XII, & SCM

-Central LND - all LN tissue from carotids laterally, hyoid superiorly, sternal notch inferiorly

MELANOMA
Staging
T1: ≤ 1 mm depth
T2: 1.01-2 mm
T3: 2.01-4 mm
T4: >4 mm
N1: 1 LN+
N2: 2-3 LN+
N3: ≥ 4 LN+
a= micromet, b= macromet, c= in transit (>2 cm away) or satellite (<2 cm away but not beyond regional LN basin)
Stage I: <1 mm
Stage II: All ≥1 mm with neg LN
Stage III: any LN+

Preoperative workup
CXR & LDH in all pts
If LN +, get CT Chest /Abdomen /Pelvis, MRI brain, PET, & BRAF testing

Treatment
≤ 0.75 mm depth: WLE (wide local excision)
0.76-4 mm: WLE + SLNB
Clinically + LN: FNA to confirm, then WLE, LN dissection, & INF or ipilimumab

WLE margins:
<1 mm depth: 1cm
1-4 mm: 1-2cm
>4 mm: 2cm

Recurrence: local excision if possible, otherwise ILP (isolated limb perfusion)
Add radiation if LN + or if extracapsular spread

Follow up
Stage I: q 3-6 month exam
All others: q 3-6 month exam + q 6 month PET CT Chest / Abdomen / Pelvis for 2 years

​LUNG CANCER (Non Small Cell)
Staging
T1: <3 cm
T2: 3-7 cm & ≥ 2 cm from carina, or invades visceral pleura, or main bronchus
T3: >7 cm or <2 cm from carina, invades chest wall, pericardium, or diaphragm
T4: invades mediastinal structures, carina, spine or has tumor in additional ipsilateral (I/L) lobe
N1: I/L bronchopulm or hilar LN
N2: I/L mediastinal or carinal LN
N3: any C/L LN
Stage I: T1 or T2
Stage II: T3N0 or T1,2N1
Stage IIIA: T3N2
Stage IIIB: any T4 or N3

Preoperative workup
CT Chest / Abdomen + PET
PFTs - need post op FEV >1L (5 lobes, 20% volume each) & DLCO >60%
Stage II or higher need MRI brain
Mediastinal LN evaluation either with mediastinoscopy, CT guided biopsy, EUS or EBUS with biopsy

Treatment
T1: surgery + LN sample
T2-3 & negative mediastinal LN: surgery + LN sample then chemoRT
N2 or T4 disease: controversial - neoadj chemoRT (cisplatin + etoposide)

Follow up

Q3-6 month exam + CT chest

ESOPHAGEAL CANCER (Adenocarcinoma)
Staging
T1a: lamina propria or muscularis mucosa
T1b: submucosa
T2: muscularis propria
T3: adventitia
T4: adjacent structures
-T4a: resectable
-T4b: non resectable

Preoperative workup
CT Chest/Abdomen, PET, & EUS

Treatment
T1a: endoscopic mucosal resection + ablation
T1b: esophagectomy
All others: neoadjuvant chemo/RT (5FU/cisplatin) then possible esophagectomy depending on response.
If +LN post op, add adjuvant chemo/RT if not given preop

Follow up
Q 3-6 month exam +/- imaging


GASTRIC CANCER
Staging
T1a: lamina propria
T1b: submucosa
T2: muscularis propria
T3: subserosa
T4a: serosa
T4b: adjacent structures
N1: 1-2 LN+
N2: 3-6 LN+
N3: >6 LN+

Preoperative workup
CT Chest/Abdomen /Pelvis, PET, EUS
If surgical candidate, diagnostic laparoscopy with cytology

Treatment
T1a: endoscopic resection
T1b: surgery
All others: neoadjuvant chemo +/- RT OR periop chemo (3 cycles preop & 3 cycles postop). Then possible surgery depending on response.
Post op: all except T1 get chemo/RT OR chemo alone (if had preop RT or D2 lymph node dissection)

Misc
Surgery: need microscopic negative margins (aim for 4 cm gross margins).
-Proximal tumors get total gastrectomy + RNY esophago-jejunostomy.
-Mid/distal tumors get distal or subtotal gastrectomy + Billroth I or II.
Lymphadenectomy: need ≥ 15 LN.
-D1: greater & lesser curve, prepyloric LN
-D2: D1 LN & celiac, left gastric, common hepatic and splenic LN
Chemo regimen: 5FU & cisplatin

Follow up
Q3 month exam
Q6 month +/- CT Chest / Abdomen / Pelvis, +/- EGD

GALLBLADDER CANCER
Staging
T1a: lamina propria
T1b: muscularis
T2: perimuscular
T3: serosa, liver, or additional organs
T4: portal vein, hepatic artery, or two additional organs

Preoperative workup
LFTs, CEA, CA 19-9, CT Chest / Abdomen / Pelvis

Treatment
T1a: cholecystectomy alone
T1b-T3: radical cholecystectomy (2 cm liver margins, CBD up to negative margins, lymphadenectomy of hepatoduodenal ligament)
≥ T2 or LN+: add adjuvant chemo/RT

Misc
GB wall layers: mucosa, lamina propria, muscularis, serosa (no submucosa)
Chemo regimen: gemcitibine/cisplatin

Follow up
Q6 month CT abdomen +/- CEA & CA 19-9

PANCREATIC CANCER
Staging
T1: <2 cm, involving only pancreas
T2: >2 cm, involving only pancreas
T3: extends beyond pancreas, no arterial involvement
T4: celiac artery or SMA involved

Preoperative workup
CA 19-9, CT Chest / Abdomen / Pelvis,  ERCP/EUS, staging laparoscopy

Treatment
Neoadjuvant chemoRT (gemcitibine) → surgery → adjuvant chemo
Palliative if arterial involvement or mets

Misc
Some may omit neoadjuvant treatment and start with surgery for T1 or T2 lesions
Use metal stents for obstructive jaundice
May perform gastrojejunostomy for relief of obstruction in advanced disease

Follow up
Q 3-6 month exam, CT Abdomen / Pelvis, CA 19-9

COLORECTAL CANCER
Staging
T1: submucosa
T2: muscularis propria
T3: peri-colorectal tissues
T4a: visceral peritoneum
T4b: other organs
N1: 1-3 LN+
N2: ≥ 4 LN+
Stage I: T1-2, N0
Stage II: T3-4, N0
Stage III: any LN+

Preoperative workup
Colon cancer: CEA, CT Chest / Abd / Pelvis, Colonoscopy
Rectal cancer: add MRI pelvis and EUS

Treatment
Colon cancer
Polyp: polypectomy sufficient if >2 mm negative margins, no lymphovascular invasion, & moderate/well differentiated
T1-3, N0: colectomy alone
T4: colectomy +/- adjuvant chemo (FOLFOX)
T4b or LN+: neoadjuvant chemo (FOLFOX) → possible colectomy. If LN thought to be negative preop, but found to be positive post op, add adjuvant chemo.

Rectal cancer
Polyp: same treatment as colon polyp
T1: transanal excision sufficient if <10 cm from anal verge, <4 cm in size, < ⅓ circumference of rectum, no lymphovascular invasion, moderate/well differentiated.
T2: LAR or APR
T3, T4, or LN+: neoadjuvant chemoRT (FOLFOX) → surgery → adjuvant chemo (FOLFOX). If RT not given preop, add it post op.

Misc
Colectomy: need ≥ 12 LN and >2 cm (but ideally 5 cm) negative margins
 
Follow up
Q3 month exam, CEA
Q6 month CT Chest / Abdomen / Pelvis
Q1 year colonoscopy (Q3 years once normal colonoscopy)

 
ANAL CANCER
Staging
T1: <2 cm
T2: 2-5 cm
T3: >5 cm
T4: organ invasion
N1: perirectal LN+
N2: unilateral inguinal or iliac LN+
N3: bilateral inguinal or iliac LN+
Stage I: T1
Stage II: T2 or T3
Stage III: T4 or LN+

Preoperative workup
DRE, inguinal LN exam, gyn exam, anoscopy, CT Chest / Abdomen / Pelvis

Treatment
Anal canal: all get Nigro protocol (5FU, mitomycin, RT)
Anal margin: all get Nigro protocol except for T1 that are well differentiated with no lymphovascular invasion (this gets wide local excision alone with 1 cm margins)
Any LN recurrence: inguinal LN dissection
Any local recurrence: APR

Follow up
Q3 month exam including LN exam and DRE
Q6 month anoscopy
Q1 year CT Chest / Abdomen / Pelvis

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