Table 1.

Effects of surgery on cancer recurrence

Effects of surgery on cancer recurrence
	Action	Consequences
Direct effect on tumor cell survival	Surgical tumor manipulation	Release of cancer cells into the bloodstream ➔ metastatic spread to distant organs
	Surgical tumor manipulation	Intraperitoneal seeding➔ Transcoelomic spread
	Surgical tumor manipulation and incision	Endothelial disruption ➔ increase hydrostatic and oncotic pressure➔dissemination of tumor cells through lymphatic routes
	Minimal residual disease in surgical margins	Local or lymphatic spread
	Action	Consequences
Indirect effect on tumor cell survival	Physiological response to perioperative stress factors	Activating the systemic inflammatory response➔ migration of macrophages, neutrophils, fibroblasts on the site of the surgery ➔ Release of cytokines, growth factors and prostaglandin➔ promoting cancer growth, lymphangiogenesis, angiogenesis, and consequent dissemination
	Physiological response to perioperative stress factors	Activating the systemic inflammatory response➔ state of relative immunosuppression➔ immune escaping of cancer cells➔appropriate microenvironment for tumor growth
	Physiological response to perioperative stress factors	Trigger the hypothalamic-pituitary-adrenal axis and the sympathetic nervous system➔ release of hormonal mediators➔ enhance tumor growth
	Physiological response to perioperative stress factors	Expression of specific genes and/or molecular pathways➔ promotion of angiogenesis, cell proliferation, and metastasis
	Physiological response to perioperative stress factors	Activation of pro-angiogenic signaling pathways➔ increasing the metastatic invasiveness