Surgical Oncology Manual

Preface
Acknowledgement
Contents
Contributors
1: Tumors of the Adrenal Gland
	Adrenal Incidentaloma
		Background
		Workup [4]
			Imaging
		Management and Follow-Up [4]
		Indications for Adrenalectomy [4–6]
	Functional Adrenal Tumors
		Pheochromocytoma
			Overview
			Workup
			Perioperative Considerations
			Genetic Testing
		Cushing Syndrome
			Overview
			Workup [4]
			Perioperative Considerations
			Autonomous Cortisol Secretion (Subclinical Cushing Syndrome (SCS))
	Primary Aldosteronism
		Overview
		Workup [4, 6, 26]
		Adrenal Vein Sampling
		Perioperative Considerations
			Prediction of Cure (Aldosterone Resolution Score)
	Adrenocortical Carcinoma
		Preoperative Workup [33]
		Prognostic Factors
		Operative Considerations
		Adjuvant and Systemic Therapy
	Metastases to the Adrenal Gland
		Workup
		Indications for Resection of Adrenal Metastasis
	References
2: Ampullary Cancer
	Introduction
	Special Notes
	Special Case: Familial Adenomatous Polyposis (FAP)
	Landmark Trials
	Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
3: Anal Cancer
	Introduction
	Terminology
	Risk Factors and Precursor Lesions
	Anal Cancer
	Prevention and Screening
		Referring to Medical Oncology
		Referring to Radiation Oncology
		Referring to Multidisciplinary Cancer Conference
	Toronto Pearls
	References
4: Breast Cancer
	Introduction
		Benign, but Worrisome
	Ductal Carcinoma In Situ
		DCIS Recurrence
		DCIS and the Axilla
			Invasive Breast Cancer
			Special Notes
		Breast-Conserving Surgery
			Absolute Contraindications to BCS
			Relative Contraindications to BCS
		Trials for BCS Versus Mastectomy
		Meta-analysis to Assess Surgical Margins in BCS for Early Breast Cancer
			Genetic Testing
	The Axilla
		Approach to the Axilla in Early-Stage Breast Cancer
			Special Notes
		Isolated Tumor Cells and Micrometastases
			Special Notes
		Extranodal Extension
		SLNB Following Neoadjuvant Systemic Therapy
		Summary: Management of the Clinically Node-Negative Axilla in Patients Who Have Not Received Neoadjuvant Chemotherapy
	Considerations of Adjuvant Treatment for Invasive Breast Cancer
		Genomic Assays
		Ovarian Function Suppression
		Locally Advanced Breast Cancer
			Special Notes
	Inflammatory Breast Cancer
	Special Considerations
		Pregnancy and Breast Cancer
			Special Notes
		Breast Cancer in the Elderly
			Special Notes
		Dense Breasts
		Paget’s Disease of the Nipple
		Male Breast Cancer
		Metastatic Breast Cancer
		Locoregional Recurrence of Breast Cancer
			Referral to Medical Oncology
			Referral to Radiation Oncology
			Referring to Multidisciplinary Cancer Conference
	Technical Aspects of Breast Surgery
		Oncoplastic Breast Surgery
	Technical Aspects of Breast Reconstruction aAfter Mastectomy
		Types of Reconstruction
			Implant-Based Reconstruction
			Autologous Reconstruction
		Timing of Reconstruction
			Surveillance [214, 215]
	Toronto Pearls
	References
5: Cholangiocarcinoma
	Introduction
		Definitions/Terminology
		Special Notes
			Special Notes
	Landmark Publications
		Referring to Medical Oncology
		Referring to Radiation Oncology
		Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
6: Colon Cancer
	Introduction
	Screening and Surveillance for Average and High-Risk Patients
		Screening
			Special Notes
		Surveillance
			Special Notes
		Hereditary Colorectal Cancer Syndromes
			Lynch Syndrome and Microsatellite Instability
			Revised Bethesda Guidelines
			Special Notes
	Polyposis Syndromes
		Familial Adenomatous Polyposis (FAP)
		Attenuated Familial Adenomatous Polyposis (AFAP)
		MUTYH-Associated Polyposis (MAP)
		Germline Testing for APC and MUTYH [15]
	Management
		Primary Localized Colon Cancer
			Special Notes
		Management of Patient Populations at High Risk for Colon Cancer
			Special Notes
		Locally Advanced Colon Cancer or Locoregional Recurrence
			Special Notes
		Colon Cancer with Distant Metastases
			Special Notes
	Landmark Publications (Table 6.9)
		Referring to Medical Oncology (See Tables 6.7 and 6.8)
		Referring to Radiation Oncology (See Tables 6.7 and 6.8)
		Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
7: Colorectal Liver Metastases
	Introduction
		Prognostic Variables
	Management of CRLM
		Initial Work-Up
		Surgical Considerations in Resectable CRLM
		Management of Synchronous CRLM
		Assessment of Resectability of CRLM [24]
		Expanding Resectability of CRLM
		Management of Unresectable CRLM
		Role of Systemic Chemotherapy
	Special Notes
		Local Therapies
		Regional Therapies
	Extrahepatic Metastases (EHM)
	Toronto Pearls
	References
8: Desmoid Fibromatosis and Dermatofibrosarcoma Protuberans
	Introduction
	Histology and Molecular Genetics
		DT
		DFSP
	Staging and Prognosis (See Table 8.1)
		DT
		DFSP
	Management (See Table 8.2)
		DT
		Special Notes
	Primary DFSP (See Table 8.4)
		Special Notes
	Metastatic DFSP (See Table 8.5)
		Special Notes
	Landmark Publications
		DT
		DFSP
	Referring to Medical Oncology
		DT
		DFSP
	Referring to Radiation Oncology
		DT
		DFSP
	Referring to Multidisciplinary Cancer Conference (MCC)
		DT
		DFSP
	Toronto Pearls
		DT
		DFSP
	References
9: Esophageal Cancer
	Introduction
	Epidemiology
	Diagnosis and Staging
		EGD and Barium Swallow
		Endoscopic Ultrasonography (EUS)
		CT
		FDG-PET/CT
		Staging, AJCC, Eighth Edition
	Treatment
		Cervical Esophagus
		Thoracic Esophagus
			Clinical Stage 0-I
				Endoscopic Resection
				Definitive Chemoradiotherapy in SCC
			Clinical Stage II-III (except cT4)
				Neoadjuvant Chemoradiotherapy Followed by Radical Surgery
				Surgery
				Definitive Chemoradiotherapy and SCC
			Clinical Stage III-IVa
			Clinical Stage IVb or Recurrent Disease
		Abdominal Esophagus and Gastroesophageal Junction Adenocarcinoma (EAC)
			Neoadjuvant and Adjuvant Therapies
			Surgical Therapy
	Summary
	References
10: Gallbladder Cancer
	Introduction
		Definitions/Terminology
	Incidental Gallbladder Cancer (IGBC)
	Staging
		CT and MRI
		PET-CT
		Staging Laparoscopy
		Routine Paraaortic (Station 16b1) Lymph Node Biopsy.
		AJCC Eighth Edition
	Management
	Landmark Publications
	Referring to Medical Oncology
	Referring to Radiation Oncology
	Referring to MCC
	Toronto Pearls
	References
11: Gastric Adenocarcinoma
	Introduction
	Risk Factors
		Special Notes
	Classification and Staging
		Histopathology
		Molecular Classification
		Staging
		Staging Workup
		Early vs. Advanced Gastric Cancer
		Management
	Early Gastric Cancer (EGC)
		Special Notes: Early Gastric Cancer
	Advanced Gastric Cancer
		Special Notes: Advanced Gastric Cancer
	Unresectable or Metastatic Gastric Cancer
		Special Notes: Unresectable or Metastatic Gastric Cancer
	Landmark Surgical Publications (D1 vs. D2 Lymphadenectomy)
	Landmark Chemotherapy and Chemoradiation Publications
	Landmark Palliative Publications
	Referral to Medical Oncology and Radiation Oncology
	Referral to Multidisciplinary Cancer Conference
	References
12: Gastrointestinal Stromal Tumor
	Introduction
		Epidemiology and Pathophysiology
		Risk Stratification
		Molecular Classification
			Special Notes
		Pediatric and Young Adults GIST
	Management of GIST in Adults
		Special Notes
		Special Notes
		Special Notes
	Management of GIST in Children and Young Adults
		Special Notes
	Landmark Trials
		Referral to Medical Oncology
		Referral to Radiation Oncology
		Referral to Multidisciplinary Cancer Team
	Toronto Pearls
	References
13: Geriatric Surgical Oncology
	Introduction
	Terminology
		Frailty for Surgeons
	Assessing Older Adults Before Cancer Surgery
		Geriatric Screening Tools
		Comprehensive Geriatric Assessment
		Estimating Surgical Risk
		Estimating Life Expectancy
	Communication and Patient-Centered Decision-Making
	Preparing for Surgery
		What Is Prehabilitation?
		Nutrition
	Caring for Older Adults After Surgery
	Toronto Pearls
	References
14: Hepatocellular Carcinoma
	Introduction
		Special Notes
		Special Notes
		Special Notes
	Landmark Publications
		Radiofrequency Ablation (Table 14.6)
		Transarterial Chemoembolization (TACE) (Table 14.7)
		Transarterial Radioembolization (Y90) (Table 14.8)
		Surgical Resection (Table 14.9)
		Transplantation (Table 14.10)
		Systemic Therapy (Table 14.11)
		Guidelines and Consensus Documents
			Referral to Medical Oncology/HCC-Focused Hepatology
			Referral to Radiation Oncology
			Referral to Multidisciplinary Cancer Conference
	University of Toronto Pearls
	References
15: Malignancy of Unknown Primary
	Introduction
	Epidemiology
	Diagnostic Workup
	Pathologic Assessment
	Molecular Testing
	Special Considerations in Workup
		Neck Mass
		Neuroendocrine Tumors (NET)
	Management of CUP
		Approach to Patients with Favorable Subtypes
		Approach to Patients with Unfavorable Prognosis CUP
	Landmark Trials
		Referral to Multidisciplinary Case Conference
		Referral to Medical Oncology
		Referral to Radiation Oncology
	References
16: Melanoma
	Introduction
	Staging
	Management
		Primary Localized Melanoma
		Regionally Metastatic Melanoma
		Adjuvant Therapy
		Distant Metastatic Melanoma
	Landmark Trials
		Systemic Therapy
	Referring to Medical Oncology (Patients with High-Risk Melanoma)
	Referring to Radiation Oncology [90, 91]
	Referring to Multidisciplinary Cancer Conference (MCC)
	Technical Aspects of Melanoma Defect Reconstruction
		Primary Closure
		Skin Graft
		Local Flaps [1]
			Advancement Flap
			Transposition Flap
			Rotation Flap
			Keystone Flap
		Regional Flaps
		Toronto Pearls
	References
		Technical Aspects of Melanoma Defect Reconstruction – References
17: Merkel Cell Carcinoma
	Introduction
	Management
	Wide Local Excision
	Sentinel Lymph Node Biopsy
	Metastatic Merkel Cell Carcinoma
	Adjuvant Therapy for Merkel Cell Carcinoma
	Indications for Post-Operative Radiation Therapy [19]
		Systemic Therapy for Merkel Cell Carcinoma
	Referring to Medical Oncology
	Referring to Radiation Oncology
	Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
18: Neuroendocrine Tumors (Gastroenteropancreatic)
	Introduction
	Pathological Classification and Grading
	Staging
	Workup
	Primary Tumor and Extent of Disease
		Imaging and Endoscopy
			Special Notes
		Functional/Somatostatin Receptor-Based Imaging Techniques
		Grading
		Endocrinopathy
		Biochemical Testing for Endocrinopathy
		Carcinoid Syndrome
		Other Biochemical Markers
	Management of Gastroenteropancreatic NETs with Locoregional Disease
		Goals of Therapy
			Incidental Finding
			Curative Intent
			Noncurative Intent
		Gastric NETs
		Duodenal NETs
			Special Notes
		Ileal/Jejunal NETs
			Special Notes
		Colonic NETs
		Appendiceal NETs
			Special Notes
		Rectal NETs
			Special Notes
		Pancreatic NETs (pNETs)
			Special Notes
		Metastatic
			Special Notes
	Medical Management in NETs
		Systemic Therapy: Adjuvant Therapy
		Systemic Therapy: Somatostatin Analogs
		Systemic Therapy: Chemotherapy
		Systemic Therapy: Biologic Agents
		Systemic Therapy: Peptide Receptor Radionuclide Therapy (PRRT)
	Perioperative Management
		Elevated u5HIAA and/or Carcinoid Syndrome
		Functional PNETs [68, 103]
		Follow-Up
	Relevant Publications on the Management of GEP NETs
	Referring to Medical Oncology
	Referring to Radiation Oncology/Interventional Radiology
	Referring to Multidisciplinary Cancer Conference (MCC)
		Toronto Pearls
	References
19: Non-melanoma Skin Cancer
	Introduction
	Clinical Presentation [3, 5]
	Management: Primary Localized Basal and Squamous Cell Carcinoma (No Evidence of Regional or Metastatic Disease) [13, 14, 25, 26]
		Management of Low-Risk Basal Cell Carcinoma and Squamous Cell Carcinoma (See Table 19.4)
		Management of High-Risk Basal Cell Carcinoma and Squamous Cell Carcinoma (See Table 19.5)
	Mohs Micrographic Surgery
	Role for Sentinel Lymph Node Biopsy
	Regional Metastatic Non-melanoma Skin Cancer
		Management of Regional and Metastatic BCC [13]
		Management of Regionally Metastatic SCC [9] (See Table 19.6)
	Referring to Radiation Oncology
	Referring to Medical Oncology
		Options
	Referring to Multidisciplinary Cancer Conference
	Toronto Pearls
	References
20: Palliative Surgical Care
	Introduction
	Evidence for Palliative Care in Surgical Oncology
	Palliative Surgery
		Goals of Palliative Surgery
		Prognostication
		Evaluation of Outcomes
	Specific Clinical Scenarios
		Malignant Bowel Obstruction
			Special Notes
		Gastric Outlet Obstruction (GOO)
		Large Bowel Obstruction (LBO)
		Biliary Duct Obstruction
		Malignant Ascites
	Symptoms
		Pain
	Pain Assessment [60–62]
		Pharmacological Pain Management
			Special Notes
			Adjuvant Analgesics
		Nausea
			Nondrug Therapy for Nausea and Vomiting [66]
		Dyspnea
			Nondrug Therapy
		Constipation
	References
21: Adenocarcinoma of the Pancreas
	Introduction
	Diagnosis and Staging
		Work-Up
		Classification and Staging
		Imaging Studies
		Tissue Diagnosis
		Biopsy for Molecular Analysis
		Staging Laparoscopy
	Biliary Decompression
	Oncologic Management
		Referring to Multidisciplinary Cancer Conference (MCC)
	Systemic Chemotherapy
		Neoadjuvant Therapy
		Adjuvant Therapy
		Referring to Medical Oncology
		Radiation Therapy
			Referring to Radiation Oncology
		Surgery
			Special Notes
	Toronto Pearls
	References
22: Peritoneal Surface Malignancies
	Introduction
	Peritoneal Carcinomatosis Arising from the Appendix
		Mucinous Appendiceal Neoplasms
		Non-mucinous Appendiceal Neoplasms
	Peritoneal Carcinomatosis Arising from the Colon And Rectum
	Peritoneal Mesothelioma
	Management of Peritoneal Surface Malignancies
		Assessment of Extent of Disease
		Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)
		Patient Selection for Surgery
			Special Note
		Histology-Based Considerations in Managing Peritoneal Surface Malignancy
			Appendix
				Role for Right Hemicolectomy
			Colon
			Mesothelioma
		Extraperitoneal Disease and Extensive Peritoneal Carcinomatosis
	Second Look Laparotomy and Prophylactic HIPEC
	Recurrent Disease and Palliation
	Other Histologies Where CRS and HIPEC May Be Considered for Peritoneal Involvement
		Gastric Adenocarcinoma
		Desmoplastic Small Round Cell Tumor
		Epithelial Ovarian Cancer
	Landmark Studies
		Appendix
		Colorectal
		Mesothelioma
	Referring to Medical Oncology
	Referring to Radiation Oncology
	Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
23: Rectal Cancer
	Introduction
	Definitions/Terminology
	Management
		Localized Rectal Cancer
		Special Notes
	Special Considerations
		Local Excision for Rectal Cancer
		Recommended Margins
		Chemoradiation in Rectal Cancer
		MRI and “Good Prognosis” Tumors [76]
		Neoadjuvant Versus Adjuvant Chemoradiation [39–41, 70, 71]
		Total Neoadjuvant Therapy (TNT)
		Short- Versus Long-Course Radiotherapy [42, 43]
		Timing to Surgery After Radiation
		“Watch-and-Wait” (W/W)
		Laparoscopic Versus Open Resection
		Transanal Total Mesorectal Excision (TaTME)
		Lateral Lymph Node Dissection (LLND)
		Locally Advanced Rectal Cancer (LARC) (See Table 23.6) and Locally Recurrent Rectal Cancer (LRRC) (See Table 23.7)
	Distant Metastatic Disease (Stage IV) (See Table 23.8)
		Special Notes
	Landmark Trials
		Referring to Medical Oncology
		Referring to Radiation Oncology
		Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
24: Retroperitoneal and Extremity Soft Tissue Sarcomas
	Introduction
		Special Notes
	Management
		Retroperitoneal Sarcoma Localized Disease
		Special Notes
		Retroperitoneal Sarcoma: Locally Recurrent Disease
		Special Notes
		Retroperitoneal Sarcoma: Metastatic Disease
		Special Notes
		Extremity Soft Tissue Sarcoma: Localized Disease
		Special Notes
		Extremity Soft Tissue Sarcoma: Locally Recurrent Disease
		Special Notes
		Extremity Sarcoma: Lung Metastases
		Special Notes
	Landmark Publications
		Retroperitoneal Sarcoma
		Extremity Soft Tissue Sarcoma
		Referring to Medical Oncology
		Referring to Radiation Oncology
		Referring to Multidisciplinary Cancer Conference (MCC)
	Toronto Pearls
	References
25: Tumors of the Thyroid Gland
	Management of Thyroid Nodules
		Background
			Staging and Prognostic Scoring Schemes
				Work-Up [5]
				FNA Biopsy [5]
	FNA Results: Bethesda Classification
	Management of Thyroid Nodule
		Management of Differentiated Thyroid Cancer (DTC)
		Surgical Approach [5]
		Perioperative Considerations
		Toronto Pearls
		When to Refer to Multidisciplinary Cancer Conference (MCC)
	Medullary Thyroid Cancer (MTC)
		Overview
	Anaplastic Thyroid Cancer (ATC)
		Overview
	References
Index