Oncosurgery

·         Adjuvant means "assisting or aiding," but we use this term to mean assisting after surgical or radiotherapeutic control of the primary tumor. Adjuvant chemotherapy is of documented benefit in the treatment of breast cancer, colorectal cancer, stomach cancer, pancreatic cancer, and ovarian and testicular tumors. Adjuvant radiation therapy is effective in reducing the risk of tumor recurrence around the surgical site. It is often used in treating patients with rectal, breast, head and neck, and stomach cancers as well as sarcomas. Conceptually, both surgery and radiation are local/regional therapies. Although chemotherapy is obviously a systemic treatment, it may help sensitize tumors to radiation. The term "neoadjuvant" doesn't really mean anything, but it is often used to describe preoperative chemotherapy or radiotherapy (which might more accurately be described as "induction" treatment).

·         Cytoreductive ("debulking") procedures are designed to decrease tumor burden. Simply reducing tumor bulk is seldom sufficient to prolong survival. For cytoreductive surgery to be beneficial, the nonsurgical (adjunctive) therapy must be highly effective-such as radiation for glioblastoma or chemotherapy for ovarian cancer.

·         Moles:

1.       Intradermal: the most benign form

2.       Junctional: the junctional component may be the site of melanoma formation

3.       Compound: intradermal and junctional together; intermediate activity

4.       Spitz: once called juvenile melanoma, it is actually a spindle cell epithelioid nevus that is quite benign

5.       Dysplastic: the most likely to turn malignant (especially in dysplastic nevus syndrome)

·         Familial melanoma syndrome:

The inherited FAMMM syndrome has been defined as the occurrence of melanoma in one or more first- or second-degree relatives and the presence of > 50 moles of variable size, some of which are atypical histologically. The risk of melanoma in this syndrome runs as high as 100% in the person's lifetime.

Genetic studies have revealed a specific gene (i.e., p16 mapped to chromosome 9) in many people with the FAMMM syndrome.

·         MELANOMA:

1.       Superficial spreading: 75% of all cases; most common

2.       Nodular: 15% of cases; most malignant; well circumscribed; deeply invasive

3.       Lentigo maligna melanoma: 5% of cases; relatively good prognosis

4.       Acral lentiginous: 5% of cases; most common type in people of color; appears on the soles, palms, subungual sites

·         The warning signs of melanoma are skin lesions that display asymmetry, irregular borders, color changes, diameter > 5-6 cm, and enlargement or elevation.

·         Dacarbazine (DTIC) is the most active single agent cytotoxic drug against metastatic melanoma. The response rate is 20%, and the average duration of response is a 6-month period free of disease. Multidrug regimens are not much more effective.

·         Time for nerve grafting after parotid cancer resection:

Interposition grafting can be performed after noncancerous frozen sections of the nerve ends have been confirmed. A nerve graft from the contralateral greater auricular nerve is usually preferred.

·         HODGKIN'S DISEASE

1. The primary role of the surgeon is to diagnose and stage the disease.
2. The cervical lymph nodes are the usual site of involvement (75%), followed by the axillary (15%) and inguinal (9%) lymph nodes.
3. The node should be removed in one piece and not crushed, clamped, or cauterized.
4. The node should go to the pathologist fresh wrapped in saline-soaked gauze.

·         Frederick Mohs developed the technique in the 1930s. It has evolved into a state-of-the-art technique for ensuring total tumor removal with minimal excision of normal skin. The procedure is done by mapping the tumor and evaluating 100% of tumor margins (normal frozen sectioning gives us around 10% of the actual margin). Specimens are evaluated on a horizontal basis (routine frozen specimens obtained by vertical sectioning). The procedure is most useful for difficult locations (particularly, functional areas of the face-near the eyelids, mouth, nose, etc.) or for difficult tumors (e.g., recurrent BCC, morpheaform or aggressive BCC, SCC)