A 70-year-old man comes to the physician because of right-sided back pain, red urine, and weight loss for the last 4 months. He has smoked one pack of cigarettes daily for 40 years. A CT scan of the abdomen shows a large right-sided renal mass. Biopsy of the mass shows polygonal clear cells filled with lipids. Which of the following features is necessary to determine the tumor grade in this patient?

Nuclear pleomorphism and nucleolar prominence

Invasion of surrounding structures

Involvement of regional lymph nodes

Size of malignant proliferation

A 63-year-old man comes to the physician because of a 1-month history of difficulty swallowing, low-grade fever, and weight loss. He has smoked one pack of cigarettes daily for 30 years. An esophagogastroduodenoscopy shows an esophageal mass just distal to the upper esophageal sphincter. Histological examination confirms the diagnosis of locally invasive squamous cell carcinoma. A surgical resection is planned. Which of the following structures is at greatest risk for injury during this procedure?

Bronchial branch of thoracic aorta

Esophageal branch of thoracic aorta

A 19-year-old woman presents to the physician for a routine health maintenance examination. She has a past medical history of gastroesophageal reflux disease. She recently moved to a new city to begin her undergraduate studies. Her father was diagnosed with colon cancer at age 46. Her father's brother died because of small bowel cancer. Her paternal grandfather died because of stomach cancer. She takes a vitamin supplement. Current medications include esomeprazole and a multivitamin. She smoked 1 pack of cigarettes daily for 3 years but quit 2 years ago. She drinks 1–2 alcoholic beverages on the weekends. She appears healthy. Vital signs are within normal limits. Physical examination shows no abnormalities. Colonoscopy is unremarkable. Germline testing via DNA sequencing in this patient shows mutations in DNA repair genes MLH1 and MSH2. Which of the following will this patient most likely require at some point in her life?

Annual colonoscopy beginning at 20–25 years of age

Surgical removal of a desmoid tumor

Prophylactic proctocolectomy with ileoanal anastomosis

Measurement of carcinoembryonic antigen and CA 19-9 yearly

A 63-year-old female with known breast cancer presents with progressive motor weakness in bilateral lower extremities and difficulty ambulating. Physical exam shows 4 of 5 motor strength in her legs and hyper-reflexia in her patellar tendons. Neurologic examination 2 weeks prior was normal. Imaging studies, including an MRI, show significant spinal cord compression by the metastatic lesion and complete erosion of the T12 vertebrae. She has no metastatic disease to the visceral organs and her oncologist reports her life expectancy to be greater than one year. What is the most appropriate treatment?

Surgical decompression and postoperative radiotherapy

Palliative pain management consultation

High-dose corticosteroids and clinical observation

A 77-year-old man is brought to the emergency department by his wife because of headache, nausea, and vomiting for 24 hours. His wife says that over the past 2 weeks, he has been more irritable and has had trouble remembering to do routine errands. Two weeks ago, he fell during a skiing accident but did not lose consciousness. He has coronary artery disease and hypertension. He has smoked one pack of cigarettes daily for 50 years. He has had 2 glasses of wine daily since his retirement 10 years ago. Current medications include atenolol, enalapril, furosemide, atorvastatin, and aspirin. He appears acutely ill. He is oriented to person but not to place or time. His temperature is 37°C (98.6°F), pulse is 99/min, respirations are 16/min, and blood pressure is 160/90 mm Hg. During the examination, he is uncooperative and unable to answer questions. Deep tendon reflexes are 4+ on the left and 2+ on the right. Babinski's sign is present on the left. There is mild weakness of the left iliopsoas and hamstring muscles. A CT scan of the head without contrast shows a high-density, 15-mm crescentic collection across the right hemispheric convexity. Which of the following is the most appropriate next step in the management of this patient?

Recombinant tissue plasminogen activator administration

Obtain an Electroencephalography

Metastasectomy indications | Oncologic Surgery Principles

🎯 Core concept - The Why & When

The goal of metastasectomy is curative intent, not palliation. It is reserved for a select group of patients where complete removal of all cancerous tissue is feasible.

Core Principle: Oligometastasis - a state of limited metastatic burden (e.g., 1-5 lesions) where metastases are amenable to targeted therapy like surgery.
Key Indications for Resection:
- Primary Tumor Control: The original cancer is removed or well-controlled.
- Complete Resectability (R0): All visible metastases can be surgically removed with negative margins.
- Patient Performance Status: Patient is fit enough to tolerate a major operation (e.g., ECOG 0-1).

⭐ A long disease-free interval (DFI) between primary tumor treatment and metastasis detection (e.g., >12-24 months) is a key positive prognostic factor.

🔪 Management - The Resectability Rules

Metastasectomy, the surgical removal of metastatic lesions, can be curative in highly selected patients. The decision to proceed is based on four classic criteria, ensuring the potential benefit outweighs the surgical risk.

📌 Mnemonic: CARS

Controlled Primary: The original tumor is resected or definitively controllable with other modalities (e.g., radiation).
All Mets Resectable: All known metastatic disease must be technically resectable with the goal of achieving negative microscopic margins (R0 resection).
Robust Patient: The patient has adequate physiologic reserve (cardiopulmonary, nutritional status) to tolerate the proposed major operation.
Solitary Organ System: No evidence of unresectable metastatic disease in other organ systems that would preclude a curative outcome.

⭐ The most common sites for curative-intent metastasectomy are the liver (especially from colorectal cancer) and the lung. The goal is always an R0 resection (microscopically negative margins), as R1/R2 resections offer no survival benefit over non-operative management.

🎯 Cancers' Common Haunts

Metastasectomy is a curative-intent option for oligometastatic disease when the primary tumor is controlled, metastases are completely resectable with negative margins ($R0$), and the patient has adequate physiologic reserve. Survival post-resection varies significantly by the primary cancer's biology and the site of metastasis.

Comparative 5-Year Survival Rates:

Primary Cancer	Common Resected Met Site	5-Yr Survival (Post-Resection)
Colorectal	Liver	~50%
Renal Cell	Lung	~40-50%
Sarcoma	Lung	~30-40%
Melanoma	Brain, GI, Lung	~10-20%

CT scan of liver with colorectal metastasis CT chest: Solitary resectable pulmonary metastasis

🎲 Complications - The Surgeon's Gambit

Systemic Risks: Standard major surgery issues (VTE, infection, bleeding).
Site-Specific Risks (Organ-Dependent):
- Liver: Post-hepatectomy liver failure (PHLF).
- Lung: Pneumothorax, prolonged air leak.
- Brain: Neurologic deficits, hemorrhage.
Oncologic Risks:
- ⚠️ Tumor Seeding: Implantation of cancer cells along surgical tracts or within body cavities (e.g., peritoneal carcinomatosis).

⭐ For liver metastasectomy, an adequate Future Liver Remnant (FLR) is critical. An FLR <20-25% (healthy liver) or <40% (damaged liver) risks fatal liver failure.

⚡ Biggest Takeaways

Primary tumor must be controlled or simultaneously resectable.

Patient must have adequate physiologic reserve for major surgery.

All metastatic disease must be completely resectable (aim for R0 resection).

No widespread, unresectable disease outside the target organ.

Sufficient post-resection organ function is critical (e.g., future liver remnant).

Most common for liver (colorectal), lung (sarcoma, CRC), and brain metastases.

A long disease-free interval (DFI) is a favorable prognostic factor.