Introduction to Surgical
By: E. Loren Buhle, Jr. Ph.D.
Surgery is the oldest form
of cancer therapy and remains one of the most important treatment components
for solid tumors. Surgery alone can be curative in patients with localized disease,
but because many patients (~70%) have evidence of micro-metastases at diagnosis,
combining surgery with other treatment modalities is usually necessary to achieve
higher response rates.
Continuing advances in
cancer surgery have improved patient outcomes and permitted more complex operative
procedures. These include:
Knowledge of the natural history
of cancer -- especially of the patterns of metastases -- provides a more scientific
basis for the selection and combination of treatment modalities. For example,
the Halstead radical mastectomy was the treatment of choice for breast cancer
in 1890 and remained the primary treatment well into the 1960s. Today, information
about the progression of breast disease and its often systemic involvement cancer
progresses and the knowledge that breast cancer is often a systemic involvement
at the time of presentation has changed the surgical approach to this disease.
Breast cancer surgery has become less radical and is frequently followed by a
radiation or chemotherapy (or both).
- improved technical ability
to perform complex, radical surgeries, as well as greater understanding about
the appropriate applications of radical surgery;
- the use of radiolabelled
monoclonal antibodies to facilitate the excision of the entire tumor;
- the use of antibiotic
therapy to reduce morbidity secondary to infection;
- advanced technology in
surgical intensive care units resulting in increased survival after radical
surgical procedures; and
- new techniques and improved
prosthetics to decrease disability and disfigurement caused by radical surgery.
Principles of Cancer Surgery
A number of principles are
used by the surgical oncologist in the management of malignant disease:
- Slow growing cancers
are the most amenable to surgical treatment.
- The initial surgery
for malignancy is more successful than secondary operations for recurrence.
This is the guiding principle behind many radical surgeries.
- A margin of normal tissue
must be excised to assure an adequate resection.
- Clinical staging
to determine the extent of disease should be completed before definitive surgery,
- Removal of the tumor
with adjacent lymph nodes is preferable to simple tumor excision (if no serious
- The patient must find
the potential impairment resulting from the surgery acceptable.
- Reconstruction and rehabilitation
are essential components of cancer surgery and postoperative care.
Types of Cancer Surgery
Surgical procedures for malignancies
may be divided into the following categories: diagnostic, staging, definitive
(curative), preventative, reconstructive, palliative, and supportive. Surgical
procedures are also used in the management of some oncological emergencies.
Tissue biopsy is essential
to confirm the diagnosis and identify the specific type of cancer (histology).
Each histologic disease type responds differently to treatment; this is a factor
in planning surgical and adjuvant therapy.
Several biopsy techniques
are used to confirm diagnosis. These include: aspiration
biopsy, needle biopsy, excisional biopsy, and incisional biopsy. The approach
used depends on the type of tumor suspected, its size, location, and characteristics
of growth. Patients will need to be taught to care for the biopsy site and to
report any complications, such as bleeding or signs of infection.
In addition to confirming
the histological diagnosis of the primary cancer, biopsy techniques are also
used to diagnose opportunistic infections in immunosuppressed patients.
Biopsy Procedures Used in the Diagnosis of Cancer
||Aspiration of cells and tissue fragments through
a needle that has been guided to a suspected malignant tissue.
||Cytologic analysis can provide a tentative diagnosis.
Since the tumor can be missed, only a positive test is diagnostically significant.
||Obtaining a core of tissue through a specially
designed needle introduced into suspected malignant tissue.
||Sufficient for the diagnosis of most tumors.
Differentiating benign and reparative lesions from malignancies is often
difficult with soft tissue and body sarcomas. Since the tumor can be missed,
only a positive test is diagnostically significant.
||Removal of a small wedge of tissue from a large
||Preferred method for diagnosis soft tissue and
||Excision of the entire suspected tumor tissue.
||Procedure of choice for small, accessible tumors
when they can be done without compromising the ultimate surgical procedure.
Staging surgeries are
performed to determine the extent of disease. The information obtained helps the
oncologist select the surgical procedure and additional therapy most appropriate
for that stage of the disease. Exploratory surgery is commonly used to stage disease
in patients with lymphomas or ovarian cancers. During staging operations, abdominal
organs are exposed and palpated for gross evidence of disease. Multiple biopsies
are taken from the peritoneal cavity.
In cases of metastatic
diease, where surgery alone would not be curative and other treatment modalities
will be used, stating surgery permits the determination of the exact extent
of the disease. Preparations may also be made for further treatment or observations;
for example, implanting radio-opague clips for tumor delination during staging
surgery. This tailoring spare the patient the morbidity associated with more
radical or unnecessary procedures that may be beneficial at certain stages but
The goal of definitive surgery
is to excise as much of the tumor as possible. During a curative surgery, the
entire tumor, associated lymphatics, a a margin of surrounding tissue are removed
as one speciment. This decreases the possibility of seeding normal tissue with
cancer cells. Surgery can be curative for early-stage cervical, breast, skin,
and vulvar cancers, among others. Ultimately, the selection of the appropriate
surgical procedure considers the size of the tumor, its anatomic extent, and the
patient's physiological status.
When patients have large
or unresectable tumors, cytoreductive or debulking surgery may be performed.
Reducing the tumor mass in certain cancers can increase the effectiveness of
subsequent radiation or chemotherapy, both of which aremo most effective against
small numbers of cancer cells. For example, cytoreductive surgery has proven
beneficial for ovarian cancer and Burkitt's lymphoma. This approach to treatment
is generally beneficial only in cancers where other treatment modalities are
effective in controlling residual disease.
Surgery may also be useful
to manage metastatic disease. When metastasis is confined to solitary lesions
or a few nodules -- as it may be to the lung, brain or liver -- surgical removal
of these specific areas is frequently of value.
Two other surgical techniques
are used in select clinical situations. Cryosurgery, where malignant
cells are destroyed by the application of liquid nitrogen, may be used for cancers
of the oral cavity, skin and prostate. Laser surgery is another procedure
used for the local excisions of laryngeal cancers and in the treatment of cervical
dysplasias. It is also used in surgeries where excessive bleeding may be a problem.
Surgery plays a limited role
in the prevention of malignancy. Surgical intervention may be indicated for a
patient with a strong family history of cancer, an underlying condition, or congenital
predisposition that increases the risk of developing cancer. For example, colectomy
may be recommended for a patient with ulcerative colitis or a history of familial
polyposis who has an increased risk of developing colon cancer. Occasionally,
prophylactic subcutaneous mastectomies are considered for women with a very strong
family history of breast cancer and previous fibrocystic disease. Before any prophylactic
surgery, patients should be informed of the statistical risks of developing malignancy
as well as the risks and benefits of prophylactic surgery.
Reconstructive surgery is becoming
more common to repair anatomical defects and improve function and cosmetic appearance
following radical surgery. Reconstructive techniques that minimize deformity and
improve the quality of life include: breast reconstruction after mastectomy, restoration
of acceptable appearance after head and neck surgery, the use of artificial joints
after surgery for sarcoma, and the use of penile implants after urological organ
Surgery can be effective in
relieving symptoms in more advanced stages of cancer. For example, when pain cannot
be controlled through pharmacoogic or behavioral interventions, the nerve pathways
can be surgically interrupted. Surgery is also indicated in patients with obstructions
related to local expansion of the tumor. Common sites of obstruction are the bowel
in colorectal and ovarian cancer, biliary obstruction in hepatobiliary tumors,
and urinary tract obstruction from cancers of the cervix, ovary, bladder, prostate
Several surgical inteverentions
are useful in the supportive care of oncology patients. Venous access devices
may be surgically inserted for administration of chemotherapy or parenteral nutrition
and blood drawing. Ventricular reservoirs permit direct delivery of chemotherapy
to the cerebrospinal fluid. Gastrostomy and jejunostomy tubes can be placed in
patients with gastrointestinal malignancies to provide enteral nutrition.