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Oncology

Oncology CUSP Surgeons

Introduction

Cancer is a deadly disease that has become one of the leading causes of death in today’s world. The prevalence of cancer has reached such scary proportions that today every family has one or more member afflicted with this disease. In the fight against cancer individual patients or their families need all the support and guidance they can get and nothing is more pertinent than awareness and knowledge which makes patients and care givers confident partners in treatment decisions.

Definition

WHO defines cancer as the uncontrolled growth and spread of cells, also called as “Malignancy” or “Malignant tumor”.

Carcinoma is the cancer that arises from inner lining of internal organs. These organs could be from the digestive tract such as stomach, esophagus, colon or gall bladder and other organ systems such as the respiratory system (Lungs and Larynx) or Genito-Urinary system (Cervix, Uterus, Ovary, Kidney, urinary bladder etc.).

Another type of cancer is Sarcoma that arises commonly from muscle or bone and rarely from the layers of internal organs.

The highlight of any cancer cell is its ability to spread from its organ of origin to other vital organs and destroy them. This spread of cancer cells takes place via bloodstream or specialized channels called as lymphatics.

Both Carcinomas and Sarcomas are colloquially addressed as “Solid” cancers in distinction from Leukemia or Blood cancer which are termed “Liquid” malignancy. Going further we will be discussing about the various “Solid” malignancies and their management.

Most common Cancer:

Every year more than 1.4 crore newly diagnosed cancer cases are recorded worldwide. With more than 88 lakh deaths world over cancer is a leading killer. According to the National institute of Cancer prevention and research (NICPR) India, the most common cancers in our country are:

MEN WOMEN
1 Lip, Oral Cavity Breast
2 Lung Cervix
3 Stomach Colo-Rectum
4 Colo-Rectum Ovary
5 Pharynx Lip, Oral Cavity

In India every year 7 lakh new cancer cases are diagnosed. With such alarming proportions there is an urgent need to combine preventive strategies and world standard treatment facilities to defeat cancer. The first step is to spread awarenessand help patients and care givers gain confidence that they are entrusting their treatment in the hands of experts.

Stages of Cancer

The description of cancer in any patient is done by defining its extent. Stage 1 and Stage 2 cancers are so called “Early” stage cancer cells in which are localized to its organ of origin.

In contrast Stage 3 cancer is “locally advanced” in which the cancer cells have spread from organ of origin and involved the Lymph nodes in the vicinity.

Stage 4 or Metastatic cancer defines a stage where the cancer cell has spread from organ of origin to involve vital organs like lungs/liver/brain.

Stage based management

Biopsy is the first step in diagnosis of cancer wherein a small sample of tissue is taken to confirm the presence of cancer. The successful management of cancer involves diagnosing the correct stage of the disease which is accomplished by using various investigations like CT scans, MRI and PET-Scan. Once the correct stage has been diagnosed a treatment plan is formulated which is based on the stage of disease.

Multimodality treatment

Successful treatment of cancer involves the combination of Surgery, Radiotherapy and Chemotherapy to complete local, regional and finally systemic therapy.

Surgery is the mainstay of treatment of Solid malignancies and offers the best chance for cure. The core principle in cancer surgery is the complete removal of tumor. This complete removal of tumor or “R-0” resection is achieved by avoiding direct handling of tumor bearing tissue and removing it with a cuff of normal tissue. “R-0” or margin negative surgery completes the “Local” phase of treatment. Except stage 1 cancer the next phase of treatment involves the sterilization of local & regional disease basin by using Radiotherapy. This “Regional” phase of treatment takes care of any invisible cancer cell in the vicinity and is important to prevent “local” recurrence. “Systemic” phase of treatment is important for all cancers Stage 2 and above.

Neoadjuvant and adjuvant therapy

In the management of cancer “one size fits all” kind of approach is incorrect. Depending upon the stage of disease the extent and scope of surgery will change and so will the need for any extra treatment with chemotherapy and/or radiotherapy.

The sequencing of Surgery, Radiotherapy and chemotherapy can be changed according to the stage of cancer to complete the Local, Regional and systemic phase of treatment.

Neoadjuvant or therapy (chemotherapy and/or radiotherapy) prior to surgery is almost a dictum now for treatment of cancer of Esophagus, Gastro-esophageal junction (GEJ), Rectum and in selected advanced cases of cancer of Ovary, breast, stomach, and lung.

As discussed almost all cancers Stage 2 and above will need some kind of “extra” treatment after curative margin negative surgery to eradicate all microscopic cancer cells which can neither be seen by the surgeon nor will they show up on any scan. This “extra” or “Adjuvant” therapy comprises of chemotherapy alone or in combination with radiotherapy.

Role and scope of Oncosurgery

Surgical treatment for cancer also called as Oncosurgery is the cornerstone in management of solid cancers. Over the last few decades the safety and efficiency of surgical treatment of cancer has increased in leaps and bounds. While dedicated Oncosurgeons have by the dint of their exclusive practice improved results for their patients, these successes have been possible because of the collaborative nature of cancer management. Advances in radiotherapy and chemotherapy have been immensely helpful in consolidating the gains of good Oncosurgery by taking care of the “regional” and “systemic” phase of treatment.It is the correct surgical treatment which is responsible for the maximum gain in survival but it is the timely addition of radiotherapy and chemotherapy which helps in improving the outcome of treatment for the patient.

Usually in Stage 4 cancers treatment is either chemotherapy alone or in combination with radiotherapy. However, with increasing safety and technological advancements in Oncosurgery selected patients with stage 4 cancer can undergo curative Oncosurgery.

Latest advances in Oncosurgery

In the very dynamic field of Oncosurgery the only constant is patient safety and complete tumor removal. Advances in Oncosurgeryhave helped in achieving these twin goals of surgery and also provide patients with benefits of quicker recovery, decreased pain and early rehabilitation.

Highlight Individual surgeries

Laparoscopic Oncosurgery

Laparoscopic or minimal invasive surgery has been evolving for last 3 decades and is now arguably the standard of care in surgery for many cancers.

Minimal invasive surgery or Key-hole surgery

One of the biggest fears of a patient undergoing cancer surgery ismutilating surgical scars, pain and prolonged recovery. Minimal access or keyhole surgery is highlighted by scars less than one cm and early recovery with minimal pain. Oncosurgeons with expertise in minimal access surgery successfully remove cancers in thorax; abdomen & pelvis and help patients experience quicker recovery with minimal pain and early return to normal activity.

Patients not only benefit from reduced hospital stay but also avoid treatment delays associated with recovery from open surgery. Early institution of adjuvant therapy (chemotherapy/radiotherapy) ensures timely completion of treatment and improved results in management of cancer.

Leading oncology forums and societies world-over advocate Laparoscopic Oncosurgery as the standard of care for esophageal, colo-rectal, uterine and cervical cancers. With increasing evidence and mature long term data on cancer outcomes laparoscopic surgery is fast evolving as the recommended approach for cancers in Lungs, Liver, pancreas, gall bladder, kidney, urinary bladder and ovary.

VATS

Video assisted thoracic surgery has revolutionized the treatment of cancer of Esophagus, Lungs and mediastinal masses. VATS provides the surgeon with the best vision, access and magnification to perform surgeries for Lung and esophageal cancer as well as mediastinal tumors.Instead of 15-20cm long incisions patients receive 3-4 incisions ranging from 5-10mm. These key-hole incisions help the patient in post-operative recovery with minimal pain and early return to daily activity.

Breast Oncology

Breast cancer patients have seen tremendous improvements in surviving cancer over the last few decades. No longer does a lady need to lose her breast in order to win over cancer. Breast Oncoplasty is a novel surgical advancement which enables the Onco-Surgeon to not only completely remove the breast tumor but recreate an aesthetically pleasing breast which is similar in shape, size and contour to the normal breast. BCS or Breast conservation surgery has enabled courageous ladies to take cancer head on with their feminity intact. The collaborative nature of chemotherapy and radiotherapy planning has enabled breast conservation to be successfully planned for selected locally advanced breast cancers too.

Cutting edge molecular and genetic testing, like BRCA 1 & 2, has enabled Oncosurgeons to predict the likelihood of a healthy lady (with strong family history) developing breast (and/or ovary) cancer and plan risk reduction surgery. Prophylactic removal of breast and ovaries in these highly selected and counseled patients reduces the risk of cancer development by as much as 90%. Simultaneous reconstruction of breast help these patients retain a positive body image and live cancer free.

Head & Neck surgery

Mutilating scars and distorted facial asymmetry after surgery for oral cancers is a thing of the past now. With advances in reconstructive micro-surgery Oncosurgeons now successfully remove extensive oral tumors and simultaneously perform reconstructive surgery for superior functional and cosmetic outcomes. Cancers of the tongue, jaw, cheek are removed and novel reconstructive surgery using patients own tissue with intact blood supply (Free-flaps) enable patients to resume eating, retain voice and complete post-operative radiotherapy for better outcomes.

Larynx or voice box preservation surgeries are an advancement which enables selected patients suffering from cancer of larynx to retain the ability to speak.

HIPEC

Advances in the combined management of advanced cancer have enabled curative therapy to be planned and executed for selected cancer patients in the last stages of their disease. Combining Surgery with simultaneous heated chemotherapy inside the abdominal cavity (HIPEC) is one of the latest advances in cancer surgery which enables selected patients with advanced and recurrent cancers of ovary; appendix, colon and stomach to undergo curative treatments who otherwise have reached the therapeutic dead-end of cancer management.

Limb salvage & Vascular Recon

Sarcomas of the limbs are rare tumors which afflict young people. These aggressive cancers earlier required amputation of limbs with a lifelong handicap for patients. Advances in vascular reconstruction have now made it possible for Oncosurgeons to not only save the life of the patients but also preserve limb function. It is with the combined use of chemotherapy and radiotherapy along with advanced surgical techniques of vascular reconstruction and tendon transfers that limb salvage is now the norm for these cancers

Metastasectomy

Stage 4 diagnosis usually heralds end of treatment for patients. These patients are traditionally offered chemotherapy as “palliative” without any intention to cure. However with increasing understanding of the behavior of certain cancers, namely cancer of colon, rectum, sarcoma, kidney, breast certain selected patients with stage 4 cancer in whom cancer has spread exclusively to either the liver or lungs can now look forward to curative surgery. Indeed the use of “Neoadjuvant” chemotherapy enables curative surgery which can be performed laparoscopically and with curative intent.

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