Principles of Surgical

Oncology
Dr. Dian Kurnia, Sp. B (K) Onk
 PENDAHULUAN

 Pembedahan  pengobatan kanker tertua dalam

sejarahnya ; sampai sekarang memegang peranan
utama sebagai treatment of choice untuk tumor
solid

 Seorang ahli bedah harus mengetahui tentang :

- natural history of deseases
- prinsip pembedahan kanker
- prinsip multimodality treatment (pembedahan, radiasi,
kemoterapi, imunoterapi, hormonal terapi dan modalitas baru
lainnya).
Haruslah dibedakan, antara seorang ahli bedah yang
mengerjakan kasus kanker hanya sekali-kali dan
seorang ahli bedah yang mengkhususkan diri terus
menerus bekerja dalam penanggulangan penyakit
kanker.

George Park

Dokter Spesialis Bedah

Konsultan Onkologi
 Dokter Spesialis Bedah
Konsultan Onkologi

 Dokter spesialis bedah yang mampu

melakukan penatalaksanaan penyakit
kanker dangan menitikberatkan pada
aplikasi pembedahan dan berpegang teguh
pada prinsip dasar bedah onkologi dalam
pencegahan dan deteksi dini, menegakkan
diagnosis, tindakan terapi, tindakan paliasi
dan rehabilitasi secara profesional meliputi :
kanker payudara, kanker kepala leher,
kanker kulit, dan sarkoma jaringan lunak.
 Sejarah Pembedahan

 Pembedahan terapi kanker dimulai sejak zaman Egyptian Middle Kingdom

(1000 BC) Edwin Smith Papyrus

 Yang mendasari radikalitas dalam operasi kanker agar tidak terjadi residif
(kambuhan) akibat tersisanya jaringan tumor Galen (AD 129/199)

 “Should not be attached with a sharp instrument,at least not when it is so

fixed in an organ that it can not be radically excised “
Albucasis (Abu’l Quasim)
 Bedah rekonstruksi pertama kanker bibir Ambroise Pare (Abad XVI)
 Kanker adalah penyakit lokal yang mengikuti pola tertentu
John Hunter (1728 – 1793)
 Sejarah Pembedahan
 1850-1950 Development of standard surgical resection techniques
Classical Radical Mastectomy (Halsted, 1894), Modified Radical Mastectomy
(Patey 1930), Simple Mastectomy & Radiation Therapy (Mc Whirter, 1941)

 1950-1960 Development of extended radical surgical procedures

Supra Radical Mastectomy (Urban, 1952)

 1960-1980 Exploration of combined modality treatment

 1980-2000 Multimodality therapy improves organ preservation and survival

Limited surgery (BCT untuk payudara (B Fisher, 1980), limb saving untuk soft tissue sarkoma )

“Sentinel Node” biopsy (Guiliano 1990). Tujuan untuk menghindari diseksi k.g.b. regional yang
tidak perlu (Ca penis, Ca Mamae, Melanoma, Ca kepala –leher).

The molecular basis of tumor biology

 Definisi Surgical Oncology

 Principle of Surgical Oncology ; Clinical Oncology  suatu subyek

yang multidisiplin dimana seni dan ilmu pengetahuan
bergabung menjadi satu mempelajari penyakit neoplasma
Ronald Raven (1985)

 Definisi Surgical Onkologi  cabang-cabang ilmu

penanggulangan penyakit kanker, meliputi aspek diagnosis,
staging, pengobatan kanker; upaya pencegahan; berdasarkan
pengetahuan basic onkologi, sifat biologi tumor dan yang
berhubungan dengan radioterapi, khemoterapi,
imunoterapi,hormonal terapi,dll
 Orangnya yang menguasai dan mempraktekkannya  Surgical
Oncologist
 Prinsip pembedahan dalam Onkologi

1. Tindakan operasi pertama untuk tujuan pengobatan

mempunyai harapan kurasi/penyembuhan yang lebih
baik. Pembedahan kedua atau berikutnya mempunyai
angka kurasi yang lebih kecil

2. Penentuan staging pre operatif yang tepat,sangat

menentukan dalam keberhasilan pembedahan

3. Eksposure lapangn operasi harus cukup luas untuk

memudahkan mengenal jaringan tumor dan jaringan
sehat sekitarnya

4. Jaringan normal disekitar tumor perlu diikutkan dalam

eksisi ; dengan demikian ahli bedah harus mengenal dan
mengetahui karateristik invsi
8
kanker.
 Prinsip pembedahan dalam Onkologi

5. Pengangkatan jaringan tumor harus bersifat tajam dan no touch

technic
6. Pengangkatan tumor primer dengan metastasis regional harus
merupakan satu kesatuan en bloc
7. Perlu pemahaman/pengalaman multidisciplinary management
untuk meningkatkan kurabilitas
8. Pada slow growing tumor/kanker berarti siklus sel yang panjang
; dalam hal ini terapi pembedahan adalah treatment of choice
9. Daya tahan penderita (host resistance) dan kondisi imunitas
sangat penting diketahui dan turut berperan dalam
menentukan keberhasilan pembedahan
9
 Role of Surgery in Cancer

 Preventive
 Diagnosis
 Treatment : Curative ? vs Palliative
 Rehabilitation

Always clarify GOAL of the surgery

 Preventive Surgery

Prophylactic surgery to prevent cancer develompment

Disease Marker Treatment

FAP APC Colectomy
MEN 2 RET Thyroidectomy
Familial Breast Cancer BRCA 1,2 Mastectomy
Familiay Ovarian ? Oophorectomy
Cancer

Cryptorchidism ? Orchiopexy
 Diagnosis with Surgery
Principles of Biopsy

To Biopsy or not to biopsy ?

Factor to be considered :
 Tumor biology
 Treatment plan
 Possibility of “iatrogenic” tumor spread
 Type of biopsy
 Avoidance of complications
Surgical detection and biopsy for tissue diagnosis

 Fine Needle Aspiration biopsy (FNAB)

 Core needle biopsy

 Incisional biopsy

 Excisional biopsy

 Surgical staging
Surgical Treatment of Cancer

 Surgery for primary cancer

 Surgery for residual disease

 Surgery for metastatic disease

 Surgery for oncologic emergencies

 Surgery for palliation

 Surgery for reconstruction and rehabilitation
 Decision Making in
Surgical Oncology
 Curative or Palliative

 Method / Strategy

 Treat the patient not only the tumor

 Personalized the individual factors:

 Perioperative status
 Pre operative staging

 Consider estimation years of survival

 Preoperative assessment

• Identified of histological diagnosis

• Identified of extends of disease (stage)
• Identified of prognostic factors
• Identified of patient condition (assessments of the
ability to tolerate the appropriate anesthetic and
surgical procedures)
• Determining goal of treatment (curative or
palliative etc)
• Determining of risk of operations
• Informed consents
 Intraoperative Findings

 Origin of the malignancy and situation to surrounding

organs (Knowledge of anatomy topography)

 Is there metastatic risk: lymphogenic, hematogenic, per

continuitatum

 Is there any metastatic lesion

 Decide curative or palliative resection (margin?)

 The first operation for curative intend give a favorable

prognosis
 Post operative assessment

 Assess for necessary of adjuvant treatment (radiation,

chemotherapy or hormonal therapy)

 Assess about the possibility of the

 complication happened
 Principles of Surgical
Resection of Tumor
 Achieve a good local control

 Adequate margin of resection

 Lymph node harvesting

 Prevention of tumor spillage

 Minimal manipulation

 Reconstruction
 Principles of
Local Control
 Local control should be at top priority

 First operation is best chance for control

 Apply basic surgical fundamentals to reduce local

recurrences

 Salvage surgery to achieve local control

 Principles of Margin

 Tumor biology, Location, Other treatments

 In general, 1 cm gross margin

 Wider margin preferable if it can be done with

minimal additional morbidity

 Goal of margin is to reduce local recurrence

 Principles of
Lymph Nodes
 Lymph node harvesting for:
1 STAGING
2 LOCAL CONTROL
3 INTERRUPT METASTATIC CASCADE

 Risk / Benefit Ratio

 Palliative Surgery

 Not a definitive surgery

 Promote quality of life:

 Release bowel, urinary and respiratory obstruction
 Pain relieve
 Bleeding control

 Comprehensive approach (chemotherapy,

hormonal, immuno and radiotherapy)

 Post operative surveillance

 Palliative Surgery

 For SYMPTOMATIC patients

 Address the highest priority symptom

 Manage expectations from patient and families

 Metastatic Disease

 Single site of metastatic disease that can be resected

without major morbidity should undergo resection

 Limited lung, liver or brain metastases can be cured by

surgical resection.

 Appropriate for cancers that not respond well to

systemic chemotherapy
Modified Radical Mastectomy and BCS
TRAMP Flap

(Slides presented
with permission
by Dr. Manik)
Thoracectomy and
Mastectomy and thoracic
Plumbage in selected Local
Advanced Breast Cancer (T4c)
Gambaran pasca “total parotidectomy”.
COMANDO OPERATION &
Reconstruction
The Expertise of Surgical Oncologist
Tongue Cancer

wide excisi and

compartmentectomy
of the floor of
the mouth
“intra lingual
lymph nodes”
Hemithyroidectomy, Total
Thyroidectomy and
Functioning Neck Dissection
Mandibular resection and
reconstruction using
Iliac crest microvascular
technique
Wide Excisi or
‘Compartmentectomy
in STS
depending on “clinical”
and biomarker
Soft Tissue Sarcoma, wide
Excision and Reconstruction

Slides Dr.Suryawisesa
Giant Embryonal
Rhabdomyosarcoma
in ”small boy”
Surgery and chemotherapy 
“molecular marker? 
resistant to chemotherapy
and poorer prognosis
 Multidisciplinary
Approach
 Surgeon

 Pathologist

 Radiologist

 Chemo / Targeted Therapy

 Radiation Therapy

 Primary physician / Social Worker

 Nursing team
 Surgical Oncology in the
“near” Future
 Preemptive surgery in populations at genetic risk for
the development of cancer
 Tissue and function-preserving improvements
 Minimally invasive and robotic surgery
 Implantable monitors
 Treatment sensitizers
 Tissue-engineered, implantable “spare parts”
 Refinements in surgical practice will be driven by the
underlying molecular basis of tumor biology
Pollock. M. D. Anderson
Fundamentals of Surgical Oncology

Biology is King
Selection is Queen
Technical maneuvers are the
Prince and Princess

Occasionally the prince and princess try to

overthrow the powerful forces of the King and
Queen, sometimes with temporary apparent
victories, usually to no long term avail
Blake Cady, MD
 Conclusions

• Surgeon has a central role in the management of

cancer

• Understanding of tumor biology and a good patient

selection along with a good surgical technique is the
key to a better management of patients with cancer
 Pembedahan untuk terapi

Rosenberg membedakan peran pembedahan terapi menjadi:

a) Pembedahan untuk terapi definitif tumor primer

b) Pembedahan untuk mengurangi masa tumor (misalnya pada

Burkitt’s limfoma,ovarium,cancer,dll)

c) Pembedahan metastasis tumor (misalnya pembuangan metastasis

pada sarkoma atau hepatic metastase pada kanker kolorektal)

d) Pembedahan pada oncologic emergency

e) Pembedahan paliatif

f) Pembedahan untuk rekonstruksi dan rehabilitasi

 Pembedahan dari primary cancer

Ada 3 hal penting tantangan bagi seorang Surgical Oncologist dalam

menentukan terapi definitif terhadap tumor solid :

- Identifikasi yang akurat dan tepat dalam menetapkan apakah suatu

kasus dapat sembuh dengan terapi lokal biasa

- Memilih dan menentukan terapi lokal yang mana yang lebih

baik,dalam pertimbangan local control,morbiditas dan kualitas hidup

- Menentukan dan memberikan terapi ajuvant/neoajuvant yang akan

memperbaiki lokal kontrol dan kontrol distant metastase
Pembedahan Debulking atau Cytoreduction
surgery = surgery for residual disease
Debulking ini hanya mempunyai manfaat apabila ada modalitas lain
yang efektif untuk mengontrol sisa jaringan tumor yang tidak terangkat

Pembedahan untuk metastase

Prinsip umum yang harus dipegang adalah apabila tumor primer
terkontrol atau sudah/dapat dioperasi dan lesi metastase tunggal dan
dapat dioperasi tanpa morbiditas yang berat

Pembedahan pada kedaruratan onkologi

Misalnya : - pada obstruksi (GIT,UT,Resp T), perforasi, perdarahan
masif