Cancer involves abnormal cells growing uncontrollably, invading nearby tissues, and spreading to other parts of the body through metastasis.
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Patients who present to a surgical oncologist typically do so because of specific physical manifestations of a tumor mass or functional disruption of an organ system. While the underlying causes of carcinogenesis are molecular and environmental, the clinical presentation that necessitates surgical evaluation is often mechanical. The symptoms are a direct consequence of the tumor’s growth kinetics, its location within a specific anatomical compartment, and its interaction with the surrounding stroma and vasculature. Understanding these symptoms requires an appreciation of the pathophysiology of mass effect, obstruction, and tissue invasion.
The most common reason people see a surgical oncologist is because they feel a lump. This lump is made up of cancer cells that have started to grow out of control. As the tumor gets bigger, it pushes aside normal tissue, causing feelings of pressure or fullness. For example, a lump in the breast, a blockage in the colon, or seizures from a brain tumor. Cancerous lumps often feel harder and more fixed than normal tissue because the tumor causes the body to build up dense scar tissue around it. This firmness is a classic sign of cancer.
Obstruction is a hallmark symptom of many solid tumors requiring surgery. A tumor growing in a hollow viscus, such as the esophagus, stomach, or colon, acts as a physical barrier to the transit of food or waste. This leads to symptoms like dysphagia, vomiting, and constipation. The pathophysiology involves the progressive narrowing of the lumen and the loss of peristaltic coordination due to infiltration of the muscular wall. In the biliary tree or the urinary tract, obstruction leads to jaundice or hydronephrosis, respectively, due to the backup of physiological fluids.
Invasion of surrounding structures can cause distinct symptoms. Pain is often a sign of perineural invasion, where cancer cells penetrate the nerve sheaths, causing neuropathic pain that is difficult to manage with standard analgesics. Invasion into blood vessels can cause hemorrhage, presenting as hemoptysis, hematemesis, or hematuria. This bleeding is due to the friability of the tumor’s neovasculature newly formed blood vessels that lack the structural integrity of mature vessels, making them prone to rupture under pressure.
The “causes” of cancers requiring surgery are multifactorial, involving a convergence of genetic susceptibility and environmental insults. For the surgical oncologist, the cause is relevant because it influences tumor biology and the extent of resection required. For instance, cancers driven by germline mutations, such as BRCA1/2 in breast and ovarian cancer, or Lynch Syndrome in colorectal cancer, often require more extensive prophylactic surgeries to remove the entire organ at risk, rather than just the tumor.
Environmental carcinogens play a significant role in the development of solid tumors. Tobacco smoke, ultraviolet radiation, and industrial chemicals induce somatic mutations that drive uncontrolled proliferation. Chronic inflammation is another potent driver. Conditions such as inflammatory bowel disease, chronic pancreatitis, or reflux esophagitis create a milieu of oxidative stress and ongoing tissue repair, increasing the likelihood of DNA replication errors and malignant transformation. This inflammatory background often leads to dense adhesions and scarring, complicating surgical dissection.
Having a large amount of cancer in the body puts a lot of stress on a patient’s metabolism, a condition called cancer cachexia. The tumor uses up sugars and proteins quickly and releases chemicals that cause the body to break down muscle and fat. This leads to severe weight loss and weakness, which can make surgery riskier. Surgeons often need to help patients improve their nutrition before surgery to make sure they are strong enough for the operation.
Furthermore, tumors can secrete paraneoplastic hormones that alter systemic physiology. A kidney tumor might secrete erythropoietin, leading to thick blood; a lung tumor might secrete PTHrP, leading to high calcium levels. These systemic effects must be medically managed to make the patient safe for anesthesia and surgery. The “cause” of these symptoms is the ectopic production of bioactive molecules by the dedifferentiated cancer cells.
Lifestyle factors such as obesity and diet are increasingly recognized as causes of surgically managed cancers. Adipose tissue is metabolically active, secreting estrogen and adipokines that promote tumorigenesis in the breast, endometrium, and colon. The chronic low-grade inflammation associated with obesity alters the extracellular matrix, creating a pro-tumorigenic niche. Surgical oncology in the obese patient presents unique technical challenges due to the depth of the surgical field and the physiology of the patient, requiring specialized equipment and anesthetic considerations.
In terms of how the body heals, a tumor acts like a wound that never finishes healing. The signals that normally help repair tissue stay turned on all the time in cancer. Cancer cells use the body’s repair systems to build their own support structures. Surgery tries to remove this abnormal tissue, but it also creates a new wound. The challenge is to make sure the body’s normal healing process takes over, rather than letting any leftover cancer signals cause problems.
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Tumors themselves usually lack pain receptors. Pain occurs when the cancer grows large enough to press on nerves, stretch the capsule of an organ (like the liver or kidney), or block a duct. Therefore, small tumors or those growing in spaces with few nerves may remain painless until they reach a significant size.
A paraneoplastic syndrome is a set of symptoms caused by the hormones or immune response to the cancer, rather than the tumor mass itself. For example, a tumor might release a hormone that raises blood calcium levels, causing confusion and dehydration, even though the cancer hasn’t spread to the brain or bones.
A biopsy provides a tissue sample that allows pathologists to examine cells’ genetic and protein profiles. By identifying specific mutations (such as EGFR or BRCA) or viral markers (such as HPV), doctors can infer the underlying cause and biological driver of the cancer, which helps determine the best surgical and medical treatments.
Chronic stress releases hormones like cortisol and catecholamines, which can suppress the immune system and promote the growth of blood vessels that feed tumors. While stress doesn’t directly mutate DNA to cause cancer, the physiological environment created by chronic stress can potentially facilitate tumor progression and metastasis.
Cancer cells are metabolically active and consume a large amount of the body’s energy. Additionally, the immune system’s response to the cancer releases chemicals called cytokines that can suppress appetite and break down muscle and fat. This combination of increased energy burning and decreased intake leads to unintentional weight loss.
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