Surgery was for a long time the only way to treat cancer and it remains the cornerstone of modern therapy.
Technical progress in surgery, anaesthesiology and intensive care has improved its efficiency.
It is now an integrated part of treatment and the exact timing of surgery is an important factor for its success. Approximately half of curable cancer patients can be cured of their disease by surgery. An efficient therapeutic association, adapted for each particular patient emerges from the restrospective study of the clinical results obtained by surgery and collegial multidisciplinary integration.
The following points are covered:
Principles of surgical oncology :
The prior common drafting of therapeutic protocols allows the diffusion of good practice recommendations and speeds up patient treatment. Prior to surgery, the surgeon should ensure that all of the necessary resources are available to him to determine whether or not he will be able to respect the protocol. Otherwise, he should discuss the case with his colleagues, (surgeons and physicians) in order to define the best treatment before taking the lancet.
Poor initial surgical treatment can never be corrected, even by the best radiotherapy or the most audacious chemotherapy. Sometimes it is wiser to immediately carry out a new surgical procedure, in the best conditions (well prepared patient, enough operating time, more competent surgeon in the specialised field).
In breast carcinoma, pre-operative stereotaxic biopsies should prove the malignant characteristics of any suspicious mammography image; for head and neck cancers, pre-operative biopsies will be performed during laryngeal endoscopies. The same should always apply for tumours of the stomach, the lungs, the colon.
Similarly, endoscopic resection of a bladder carcinoma through loop excision is required before cystectomy.
Only in exceptional cases should surgery be exploratory without previous knowledge of cancer diagnosis.
In these situations, the surgeon should be surrounded by suitably competent histology specialists in order to obtain the extemporaneous examination of surgical biopsies. This is most important for confirming a breast or thyroid cancer before any surgical amputation. The pathological certainty is mandatory (be it, in some cases, only for medico-legal reasons).
In the majority of so-called emergency situations, the pre-operative diagnosis has not been sufficiently backed up by paraclinical adapted examinations and the surgeon should know, in advance, what surgical situation he will discover and what kind of excisions he will have to perform, thus anticipating enough operating time, intensive care necessity as well as blood supply to enable him to work in comfortable and secure circumstances.
Many studies have shown that patients have a better prognosis if surgery is carried out by an oncology surgeon (for head and neck, ovarian and breast cancers).
All the necessary procedures should be followed to prepare patients for the surgical operation (for instance digestive preparation for ovarian carcinoma due to the possibility of intestine surgery) with pre-operative reanimation or alimentation.
The ease of the post-operative recovery is of utmost importance: simple effects will allow the rapid setting up of adjuvant therapies which are mandatory to increase the patient’s chances of survival; on the contrary, difficult effects with complications like infections, fistulae, haemorrhage, surgery resumption, will slow down the commencement of other therapies, thus reducing the patient’s chances of survival.
The surgical operative report :
The surgical operative report is one of the most important elements of the patient's cancer file.
Its thorough study allows a clear judgement on the quality of the surgical procedure.
The surgical operative report should be written as soon as possible, (at best when the surgeon leaves the operating theatre). It should explicitly describe each and every difficulty encountered and the duration of the operation.
Diagnostic surgery :
The biopsy
(tumour differentiation, histological grading, importance of vascularisation,
importance of stromal reaction, presence of lymph or venous emboli, research of hormone
receptors by immunochemistry, research of growth factor receptors by immunochemistry,
research of oncogenes by in situ hybridisation, ploidy study by flow cytometry).
If the biopsy is to be followed by excision, the surgical approach should be direct in order to allow the performance of the excision without any risk of healthy tissue contamination by cancer cells.
A node biopsy with complete removal of the node is necessary for the diagnosis of lymphoma in order to study node morphology. When dealing with node metastases (from another primitive tumour), partial sampling may be sufficient (for instance Tru-cut forceps biopsy), particularly if the node is fixed to neighbouring tissue (the excision could become traumatic).
Laparoscopic colon surgery is a technique whereby the colon can be removed using several small incisions. The use of smaller incisions leads to less pain after surgery, less time in the hospital, and a quicker return to work and full activity. However, this specialized procedure cannot be performed on all patients who need colon surgery.
Laparoscopy is also often performed for inventory surgery (such as second look laparotomy or laparoscopy in ovarian carcinoma).
Some surgeons fear the constitution of tumour implants on the various sites in contact with the trocars necessary for laparoscopic surgery: a carbon dioxide overpressure is instituted inside the abdomen which might favour tumour dissemination towards less resistant zones such as trocar holes.
An extra-peritoneal laparoscopy can be performed for laparoscopic radical prostatectomy. The urologist makes several small incisions (around 1cm long) in the patient’s abdomen. A laparoscope – a long, thin, lighted telescope – is then inserted through one of the incisions.
Tiny surgical instruments, held by robotic arms, are inserted into the other incisions. The surgeon uses the robot to control their movements. Mini-cameras on the instruments send images to video monitors.
These images are larger than life, magnified many times, allowing the surgery to be extremely precise.
However, even if the tumour extension seems beyond any therapy, a diagnostic biopsy should always be performed (some non tumour pathologies can mimic cancer, at least macroscopically). If the tumour can also be treated by other therapies (such as chemotherapy for ovarian carcinoma), a voluntarist but reasonable excision should be attempted.
In contrast, a precise description of the lesions is necessary for tumour classification and to evaluate the effectiveness of new treatment (ovary, colon).
Radical surgery :
For the surgeon, the excision limits are evaluated as the distance between the tumour and the zone where, statistically, no tumour is found.
In difficult situations, the determination of this border could be significantly improved by the precise marking of the excision limits (by china ink for instance) and the performance of extemporaneous histological examinations. A trust-based dialogue should be established between the surgeon and the pathologist during the operative procedure in order to define a satisfactory excision.
For digestive tumours, such interventions are performed:
.In gynaecological surgery, an enlarged colpo-hysterectomy with bilateral iliac lymphadenectomy is the standard surgery for cervix uteri or corpus uteri cancer.
In Urology, for treating testicular cancer, an orchidectomy through an inguinal approach should be performed, including the ligature of spermatic cord as high as possible, in order to avoid any remote dissemination. The scrotum approach would be a mistake.
For treating bladder carcinoma, in male patients, cystectomy is a radical prostato-cystectomy with a possible ileal bladder reconstruction. The external sphincter is preserved and the patient can re-educate himself and obtain correct bladder autonomy (occasionally with night incontinence).
Among women, such an artificial bladder is difficult to realise since the external sphincter is difficult to isolate. Very often, an external derivation is mandatory with a trans-ileal pseudo-bladder called a Bricker intervention and the use of urinary external appliance. (Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North America. 1950; 30: 1511-2).
The good good positionning of the stomy, its regular maintenance and the patient's education necessitate the presence of a stomatherapy nurse. Over and above their purely technical role, these nurses offer help and psychological support which are essential when facing such mutilation.
For ovarian carcinoma, which is clinically manifested by a diffuse peritoneal carcinomatosis, the importance of excision and of residual tumours left after the first surgical procedure, is the major prognostic factor just after staging. Thus, an optimal resection is the goal of such surgery.
The surgeon’s aggressiveness, the correct patient preparation (intestinal preparation) and the duration of the surgical procedure have a positive influence on survival. However, it is clear that a macroscopically complete excision of any tumour lesion does not provide the assertion that no microscopic lesions remain. For these reasons, some surgeons have proposed a complete excision of the parietal and parenchymentous peritoneum: however this excision induced many complications with difficult operative recovery which delayed the mandatory adjuvant chemotherapy. Such surgical procedures have, therefore, been abandoned.
For tumours where complete excision was impossible at the time of first surgery, an interim laparotomy with complete tumour excision, if the tumour responds well to chemotherapy, improves patient survival.
For prostate cancer, the radical prostatectomy will be performed but at the same time the surgeon will try to protect erection nerves and urinary continence. Thus, quite often, the limits may be pathological and an adjuvant local radiotherapy is necessary.
In Head and Neck surgery, the anatomical limits are often very close to the excision limits. Complementary radiotherapy is therefore frequent.
The goal of systematic lymphadenectomy is to determine the evolutive potential of the cancer. Node invasion is one of the best prognostic factors: the more positive nodes are, the poorer the prognosis.
Curage is carried out starting from the tumour and according to the general observation of successive node invasion from one level to the next. 'Skip metastases' (metastases that 'jump' a level) are rare no matter what type of cancer is involved.
In general, lymphadenectomy only concerns the first levels, since, beyond them, the cancer is considered as already potentially metastatic. The surgical excision of invaded nodes does not seem to modify prognosis (no clear clinical study in favour of this attitude), but will provoke major negative consequences.
In order to avoid useless sequellae (noticeable lymphoedema of the arm or the leg), research has been carried out to find the minimal tumour volume beneath which the nodes are generally not invaded, thus node dissection becomes futile (for instance: mammary tumour below 5 mm or micro-invasive cervix carcinoma).
In mammary surgery, study of the 'sentinel node' (i.e. the first node level) is most interesting with the use of detection techniques either by colorimetry (Evans Blue) or by radio-colloid. There is a major deteriorating prognostic value of positive node.
The study of adenopathies (particularly of capsule invasion which signifies the invasion of adjacent tissue resulting in node fixation) is of utmost interest in Head and Neck cancer. The size of the adenopathies reduces the efficiency of radiotherapy and surgical excision is, therefore, often performed.
For certain cancers where surgery is mutilating (such as radical prostatectomy or cystectomy), the first surgical time is the node sentinel biopsy with an extemporaneous study of the specimen: if there are positive nodes, radical surgery should be discussed (great risk of remote metastases).
Limited cancer surgery :
However, the concept of 'en bloc' surgery has been strongly debated, since the observation, even for limited disease, of remote metastases and has resulted in surgical procedures in better conformity with the tumour biology.
Quite often, the mutilating surgery does not cure the patient because the cancer disease has already spread outside of the therapeutic possibilities offered by surgery (or radiotherapy).
On the contrary, randomised studies have demonstrated that less radical surgical procedures offered identical survival results. Nevertheless, even taking this into account, surgery remains the major cancer therapy in approximately 80% of cases.
Randomised studies have demonstrated that mammary lumpectomy (tumour ablation with a small security limit) when followed by complementary radiotherapy has the same efficiency as radical mastectomy. The major prognostic factor is the state of satellite nodes. The dimension of the local surgical resection does not modify risks in terms of local control or remote metastases.
When nodes are positive or if the tumour is poorly differentiated, adjuvant chemotherapy or hormonotherapy play an important therapeutic role. The local surgical procedure is secondary in these cases.
Compilation of three large randomised trials demonstrating the equivalence of radical mastectomy (with lymphadenectomy) and single lumpectomy (with lymphadenectomy) followed by radiotherapy.
For some cancers, the only ambition of surgery is to reduce a maximum amount of tumour volume before the use of other potential therapies (such as chemotherapy).
The most significant example is ovarian carcinoma.
For a certain number of tumours, surgery has been a very important tool to evaluate the response to chemotherapy.
One of the most typical examples has been the 'second look laparotomy' in ovarian carcinoma. This procedure was systematically performed in order to evaluate the response to chemotherapy and to enable the conclusion of treatment. In reality, it has been demonstrated that such surgery did not modify patient survival (probably because currently available salvaging treatment is insufficient for modifying disease evolution). Second laparotomy is nowadays only performed within clinical trials.
A variant was defined for ovarian carcinoma with an initial incomplete surgical procedure. A second laparotomy is planned after 3 months’ chemotherapy in the hope to perform the complete excision of each tumour nodule.
Post chemotherapy lymphadenectomies are another example. They are performed in order to assess the absence of any viable residual tumour.
For instance, in testicular cancer presenting with voluminous lumboaortic masses and for which persistent node masses are revealed by scanner after 4 chemotherapy courses:
The lymphadenectomy will specify the state of the nodes:
Nowadays, before practising such surgery, a Pet-Scan is performed. The first two cases do not show any FDG uptake (no viable tumour). FDG scintigraphy might avoid unnecessary surgery with its potential morbidity.
However, occasionally, satisfactory or simply palliative excisions may be proposed when the tumour relapses after radiotherapy.
Some examples:
The occurrence of metastases in the first months or years after tumour excision generally signifies that the metastasis was already present at the time of surgery but was too small to be identified by usual methods.
Improved knowledge of the biology of cancer enables the proposed excision of metastases with a good chance of success:
A noticeable exception might be the presence of multiple pulmonary metastases of a testicular teratocarcinoma matured through chemotherapy (no uptake with FDG scintigraphy) and which could relapse later.
All of these surgical procedures have a 'curative' intent (or at the very least they offer relief with good survival and quality of life).
On the other hand, an osseous metastasis does not imply imminent patient death. However, it could imply considerable physical decline for the patient (bed immobilisation, risk of bedsores, dependency on the family circle, frustration faced with incapacity). Vigorous treatment is therefore of great help.
Rapid surgical repair of pathological fractures is therefore recommended when feasible and when it offers prompt patient mobilisation.
Some examples:
When rachis metastases occur (osseous or meningeal metastases) with medullar compression (paraparesia or paraplegia), the ideal delay for surgical treatment is less than 24 hours. After 24 hours, vascular damage due to medullar compression renders possible movement recovery uncertain. Thus, the diagnosis of medullar compression should be treated as an emergency and the patient should immediately be referred to a surgeon for decompression and fixation. Complementary radiotherapy may also be useful.
If the delay is too long, then the patient will suffer from long painful and upsetting agony which could have been avoided (the patient’s death cannot be avoided however its dreadful conditions can).
Pre-fracture syndromes
The apparition of prefracture pains is another surgical emergency: the bone is damaged to such an extent that every movement is painful and the risk of complete fracture is very high. A surgical procedure for preventive consolidation could be associated with other measures such as localised radiotherapy or morphine treatment.
Some examples:
Sometimes, tumour excision, even if it is not satisfactory in terms of survival, may be useful if involving uncomplicated postoperative recovery and requiring limited hospitalisation: the quantity of recurrence-free life and quality of life should be promoted.
Since they are more easily accepted by patients, it is also possible to carry out internal derivations:
The implantation of an oesophageal prosthesis using endoscopy, of an ureteral prosthesis by a percutaneous puncture or during cystoscopy, and the use of a colic prosthesis or a venous stent for protecting the patient from a superior cave syndrome are all very useful 'palliative surgical procedures'.
Tumour necrosis is very frequent around developed disease and, not only painful, its odour, bleeding and ugliness can also be very unpleasant for the patient and his/her family. Certain particularly neglected tumours have left us with horrifying pictures.
A simple excision can offer comfort and cleanliness: mastectomy, resection of an intestinal tumour despite hepatic metastases or derivation for fistulae.
In practice only two locations are concerned: breast carcinoma (for which a surgical ovariectomy or pelvic irradiation may be proposed) or prostate carinoma (for which bilateral surgical castration may be proposed).
The psychological trauma for the patient should be prevented through thorough and attentive explanations.
However, most often, in order to avoid such explanations, the physician will prefer to treat medically (anti-hormone products: anti-androgens or anti-estrogens, chemical castration by a LH-RH analogue - see chapter on hormonotherapy). The results are identical although the cost is much higher.
Reconstruction surgery :
Most excision surgical procedures aim at preserving body functions as far as possible.
However, satisfactory cancer surgery involves a number of necessary mutilations.
Thus, reconstruction surgery becomes a very important phase in the rehabilitation of cured patients.
Occasionally, the reconstructive surgery can be carried out at the same time as the excision procedure:
However, it should be clear that despite progress, the results are not a restitutio ad integrum. For this reason, and to avoid the disappointment induced by an imperfect result, many surgeons advise delaying mammary reconstruction until such times as all other treatments are concluded. Thus, all adjuvant treatments can be administered at full dose without paying attention to potential damage to the aesthetic surgery.
And finally, it should be clearly accepted that an imperfect result is always better than no correction at all.
Pain surgery is aimed at very specific situations when common analgesic treatment has no effect.
They are generally anaesthetic procedures carried out in a surgical theatre:
Technical progress in surgery, anaesthesiology and intensive care has improved its efficiency.
It is now an integrated part of treatment and the exact timing of surgery is an important factor for its success. Approximately half of curable cancer patients can be cured of their disease by surgery. An efficient therapeutic association, adapted for each particular patient emerges from the restrospective study of the clinical results obtained by surgery and collegial multidisciplinary integration.
The following points are covered:
General principles of cancer surgery
Surgery for diagnosis
- The multidisciplinary pre-therapeutic discussion
- The surgical operative report
- Usual clinical situations
Radical surgery
Limited surgery
- The concept of en bloc excision
- Main clinical situations
- Limits of en bloc excision
- Role of elective lymph node dissection
Tumour reduction surgery
- Example of breast cancer
- Other examples
Evaluation surgery
Relapse and metastasis surgery
Palliative surgery
Reconstruction surgery
Pain surgery
Principles of surgical oncology :
The pre-surgical multidisciplinary discussion
Except in emergency situations, surgery should be planned within the therapeutic protocol. The discussion with the other members of the multidisciplinary team should provide the definition of the best surgical intervention for each patient.The prior common drafting of therapeutic protocols allows the diffusion of good practice recommendations and speeds up patient treatment. Prior to surgery, the surgeon should ensure that all of the necessary resources are available to him to determine whether or not he will be able to respect the protocol. Otherwise, he should discuss the case with his colleagues, (surgeons and physicians) in order to define the best treatment before taking the lancet.
Poor initial surgical treatment can never be corrected, even by the best radiotherapy or the most audacious chemotherapy. Sometimes it is wiser to immediately carry out a new surgical procedure, in the best conditions (well prepared patient, enough operating time, more competent surgeon in the specialised field).
Previous knowledge of tumour histology
This is one of the most important concepts in surgical oncology: the surgeon should already know what kind of histological tumour he is going to remove.In breast carcinoma, pre-operative stereotaxic biopsies should prove the malignant characteristics of any suspicious mammography image; for head and neck cancers, pre-operative biopsies will be performed during laryngeal endoscopies. The same should always apply for tumours of the stomach, the lungs, the colon.
Similarly, endoscopic resection of a bladder carcinoma through loop excision is required before cystectomy.
Only in exceptional cases should surgery be exploratory without previous knowledge of cancer diagnosis.
In these situations, the surgeon should be surrounded by suitably competent histology specialists in order to obtain the extemporaneous examination of surgical biopsies. This is most important for confirming a breast or thyroid cancer before any surgical amputation. The pathological certainty is mandatory (be it, in some cases, only for medico-legal reasons).
In the majority of so-called emergency situations, the pre-operative diagnosis has not been sufficiently backed up by paraclinical adapted examinations and the surgeon should know, in advance, what surgical situation he will discover and what kind of excisions he will have to perform, thus anticipating enough operating time, intensive care necessity as well as blood supply to enable him to work in comfortable and secure circumstances.
A surgical procedure that is well planned and as complete as possible
In spite of important recent progress in other treatments, the surgical procedure remains the best therapy in the majority of cancers. It must, therefore, be carried out by a surgeon belonging to a multidisciplinary team, but who perfectly appreciates the power and the limits of his acts and who anticipates the adjuvant therapies (such as radiotherapy or chemotherapy).Many studies have shown that patients have a better prognosis if surgery is carried out by an oncology surgeon (for head and neck, ovarian and breast cancers).
All the necessary procedures should be followed to prepare patients for the surgical operation (for instance digestive preparation for ovarian carcinoma due to the possibility of intestine surgery) with pre-operative reanimation or alimentation.
The ease of the post-operative recovery is of utmost importance: simple effects will allow the rapid setting up of adjuvant therapies which are mandatory to increase the patient’s chances of survival; on the contrary, difficult effects with complications like infections, fistulae, haemorrhage, surgery resumption, will slow down the commencement of other therapies, thus reducing the patient’s chances of survival.
The surgical operative report :
The surgical operative report is one of the most important elements of the patient's cancer file.
Its thorough study allows a clear judgement on the quality of the surgical procedure.
The surgical operative report should be written as soon as possible, (at best when the surgeon leaves the operating theatre). It should explicitly describe each and every difficulty encountered and the duration of the operation.
A detailed description of observed lesions is essential
- size of the primitive tumour,
- its precise location,
- its spread to neighbouring structures,
- its adhesion to nearby organs,
- the size and locations of pathological nodes
A clear description of surgical acts
- acts which were actually realised,
- but also those that were not carried out for technical or other reasons,
- the precise location of clips left on residual tumours,
- a precise description of tumours left after surgery,
- a precise description of the surgical specimens collected in clearly labelled containers,
- specific samples for molecular biology.
A precise description of the completeness of surgery
- Clear description of this completeness,
- Description of the carcinologic nature of surgery (free limits),
- On the contrary, description of resections taken from the tumour,
- Precise location and description of tumour left after surgery.
Preparation for the histological study
Such skilful preparation enables the pathologist to carry out a quality examination and to respond precisely on surgical limits and completeness of the excision, and the biologist to progress with knowledge of each patient’s tumour.
- Collection in separated containers of the different surgical specimens,
- Well oriented surgical specimens
- Surgical specimens that have not been fragmented by an immediate, incompetent or even harmful post surgical exploration,
- Surgical specimens immersed in preserving liquid (formalin or other new liquids) if the transportation duration is long.
- Special samples for molecular biology (immediate transmission and preservation)
- Special samples for tissue culture (specific culture media).
Diagnostic surgery :
Biopsy
The biopsy technique varies according to the organ concerned and the type of cancer. Several quality criteria should be respected.The biopsy
- uses an instrument which does not cause any crush nor coagulation of the sampled tissue (cold lancet, biopsy forceps),
- should be pertinent and should represent the whole tumour,
- suould avoid haemorrhaging, necrotic or infected zones,
- should concern junction zones between healthy tissue and tumour (for instance the implantation foot of polyp tumours),
- Should avoid any bleeding or abscess which would slow down further treatment,
- Should provide sufficient tissue to allow a good quality histological study,
- Should allow the study of other biological criteria necessary for a quality classification:
(tumour differentiation, histological grading, importance of vascularisation,
importance of stromal reaction, presence of lymph or venous emboli, research of hormone
receptors by immunochemistry, research of growth factor receptors by immunochemistry,
research of oncogenes by in situ hybridisation, ploidy study by flow cytometry).
If the histological response is uncertain, we should not hesitate to repeat the biopsy in order not to reject the hypothesis of cancer or, on the contrary, to propose mutilating surgery without formal proof of malignancy.
If the biopsy is to be followed by excision, the surgical approach should be direct in order to allow the performance of the excision without any risk of healthy tissue contamination by cancer cells.
A node biopsy with complete removal of the node is necessary for the diagnosis of lymphoma in order to study node morphology. When dealing with node metastases (from another primitive tumour), partial sampling may be sufficient (for instance Tru-cut forceps biopsy), particularly if the node is fixed to neighbouring tissue (the excision could become traumatic).
Laparoscopy
Its popularity is currently on the increase; a great number of excisions are now performed using an endoscopic approach. However, one should consider that safe cancer surgery should consist of a complete excision, with healthy limits and no tumour spreading due to tumour manipulation. Such precautions are not always easy to take during laparoscopy.Laparoscopic colon surgery is a technique whereby the colon can be removed using several small incisions. The use of smaller incisions leads to less pain after surgery, less time in the hospital, and a quicker return to work and full activity. However, this specialized procedure cannot be performed on all patients who need colon surgery.
Laparoscopy is also often performed for inventory surgery (such as second look laparotomy or laparoscopy in ovarian carcinoma).
Some surgeons fear the constitution of tumour implants on the various sites in contact with the trocars necessary for laparoscopic surgery: a carbon dioxide overpressure is instituted inside the abdomen which might favour tumour dissemination towards less resistant zones such as trocar holes.
An extra-peritoneal laparoscopy can be performed for laparoscopic radical prostatectomy. The urologist makes several small incisions (around 1cm long) in the patient’s abdomen. A laparoscope – a long, thin, lighted telescope – is then inserted through one of the incisions.
Tiny surgical instruments, held by robotic arms, are inserted into the other incisions. The surgeon uses the robot to control their movements. Mini-cameras on the instruments send images to video monitors.
These images are larger than life, magnified many times, allowing the surgery to be extremely precise.
Exploratory laparotomy
Its role has declined in relation to the increasing value of diagnostic techniques such as scanner, RMI or PetScan.However, even if the tumour extension seems beyond any therapy, a diagnostic biopsy should always be performed (some non tumour pathologies can mimic cancer, at least macroscopically). If the tumour can also be treated by other therapies (such as chemotherapy for ovarian carcinoma), a voluntarist but reasonable excision should be attempted.
In contrast, a precise description of the lesions is necessary for tumour classification and to evaluate the effectiveness of new treatment (ovary, colon).
Radical surgery :
The concept of large en bloc excision
This concept is based on tumour spread rendering impossible for the surgeon to be certain of the excision limits: for this reason, radical surgery should remove, in one piece, the tumour, a large portion of the organ bearing the tumour, the connective tissue around it together with the lymph vessels and regional lymph nodes. The great probability of extension to regional nodes implies the surgical removal of those satellite nodes, even if, macroscopically, they seem unharmed. At least the first lymph node level should be removed and all the connective tissue between the tumour and these nodes where the lymph vessels are found.For the surgeon, the excision limits are evaluated as the distance between the tumour and the zone where, statistically, no tumour is found.
In difficult situations, the determination of this border could be significantly improved by the precise marking of the excision limits (by china ink for instance) and the performance of extemporaneous histological examinations. A trust-based dialogue should be established between the surgeon and the pathologist during the operative procedure in order to define a satisfactory excision.
Main radical excisions
Here is a non exhaustive list of some radical excisions:For digestive tumours, such interventions are performed:
For mammary tumours, radical mastectomy is still performed (or Halstedt intervention or Patey intervention which respects the pectoral muscle), with ablation of the mammary gland, the skin, the axillary wall and cellular tissue of the armpit. Until they benefit from a breast reconstruction surgery, patients require to wear a mammary prosthesis in their bra.
- radical oesophagectomy for oesophageal cancer,
- total or large gastrectomy, with complete node dissection,
- right hemicolectomy for caecum cancer with lymphadenectomy up to colic artery origin.
.In gynaecological surgery, an enlarged colpo-hysterectomy with bilateral iliac lymphadenectomy is the standard surgery for cervix uteri or corpus uteri cancer.
In Urology, for treating testicular cancer, an orchidectomy through an inguinal approach should be performed, including the ligature of spermatic cord as high as possible, in order to avoid any remote dissemination. The scrotum approach would be a mistake.
For treating bladder carcinoma, in male patients, cystectomy is a radical prostato-cystectomy with a possible ileal bladder reconstruction. The external sphincter is preserved and the patient can re-educate himself and obtain correct bladder autonomy (occasionally with night incontinence).
Among women, such an artificial bladder is difficult to realise since the external sphincter is difficult to isolate. Very often, an external derivation is mandatory with a trans-ileal pseudo-bladder called a Bricker intervention and the use of urinary external appliance. (Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North America. 1950; 30: 1511-2).
The good good positionning of the stomy, its regular maintenance and the patient's education necessitate the presence of a stomatherapy nurse. Over and above their purely technical role, these nurses offer help and psychological support which are essential when facing such mutilation.
Limits of such en bloc surgery.
However, this concept is often difficult to apply, thus explaining many surgical failures.For ovarian carcinoma, which is clinically manifested by a diffuse peritoneal carcinomatosis, the importance of excision and of residual tumours left after the first surgical procedure, is the major prognostic factor just after staging. Thus, an optimal resection is the goal of such surgery.
The surgeon’s aggressiveness, the correct patient preparation (intestinal preparation) and the duration of the surgical procedure have a positive influence on survival. However, it is clear that a macroscopically complete excision of any tumour lesion does not provide the assertion that no microscopic lesions remain. For these reasons, some surgeons have proposed a complete excision of the parietal and parenchymentous peritoneum: however this excision induced many complications with difficult operative recovery which delayed the mandatory adjuvant chemotherapy. Such surgical procedures have, therefore, been abandoned.
For tumours where complete excision was impossible at the time of first surgery, an interim laparotomy with complete tumour excision, if the tumour responds well to chemotherapy, improves patient survival.
For prostate cancer, the radical prostatectomy will be performed but at the same time the surgeon will try to protect erection nerves and urinary continence. Thus, quite often, the limits may be pathological and an adjuvant local radiotherapy is necessary.
In Head and Neck surgery, the anatomical limits are often very close to the excision limits. Complementary radiotherapy is therefore frequent.
Role of node curage (lymphadenectomy)
Our discussion does not concern necessary lymphadenectomy carried out because of clinically invaded nodes and for which the excision is presumed to have a therapeutic value.The goal of systematic lymphadenectomy is to determine the evolutive potential of the cancer. Node invasion is one of the best prognostic factors: the more positive nodes are, the poorer the prognosis.
Curage is carried out starting from the tumour and according to the general observation of successive node invasion from one level to the next. 'Skip metastases' (metastases that 'jump' a level) are rare no matter what type of cancer is involved.
In general, lymphadenectomy only concerns the first levels, since, beyond them, the cancer is considered as already potentially metastatic. The surgical excision of invaded nodes does not seem to modify prognosis (no clear clinical study in favour of this attitude), but will provoke major negative consequences.
In order to avoid useless sequellae (noticeable lymphoedema of the arm or the leg), research has been carried out to find the minimal tumour volume beneath which the nodes are generally not invaded, thus node dissection becomes futile (for instance: mammary tumour below 5 mm or micro-invasive cervix carcinoma).
In mammary surgery, study of the 'sentinel node' (i.e. the first node level) is most interesting with the use of detection techniques either by colorimetry (Evans Blue) or by radio-colloid. There is a major deteriorating prognostic value of positive node.
The study of adenopathies (particularly of capsule invasion which signifies the invasion of adjacent tissue resulting in node fixation) is of utmost interest in Head and Neck cancer. The size of the adenopathies reduces the efficiency of radiotherapy and surgical excision is, therefore, often performed.
For certain cancers where surgery is mutilating (such as radical prostatectomy or cystectomy), the first surgical time is the node sentinel biopsy with an extemporaneous study of the specimen: if there are positive nodes, radical surgery should be discussed (great risk of remote metastases).
Limited cancer surgery :
However, the concept of 'en bloc' surgery has been strongly debated, since the observation, even for limited disease, of remote metastases and has resulted in surgical procedures in better conformity with the tumour biology.
Quite often, the mutilating surgery does not cure the patient because the cancer disease has already spread outside of the therapeutic possibilities offered by surgery (or radiotherapy).
On the contrary, randomised studies have demonstrated that less radical surgical procedures offered identical survival results. Nevertheless, even taking this into account, surgery remains the major cancer therapy in approximately 80% of cases.
The example of breast cancer
In breast cancer, the presence of invaded axillar nodes is the manifestation of the metastatic diffusion of cancer cells. The complete removal of all lymph vessels and nodes is of no therapeutic utility: nodes are more the reflection of the metastatic process than the agents of its propagation.Randomised studies have demonstrated that mammary lumpectomy (tumour ablation with a small security limit) when followed by complementary radiotherapy has the same efficiency as radical mastectomy. The major prognostic factor is the state of satellite nodes. The dimension of the local surgical resection does not modify risks in terms of local control or remote metastases.
When nodes are positive or if the tumour is poorly differentiated, adjuvant chemotherapy or hormonotherapy play an important therapeutic role. The local surgical procedure is secondary in these cases.
| Reference | Number of patients | Protocols | Follow-up | Local relapse | Disease free survival | Global survival |
| Blicherttoft (1995) | 429 430 | Mastectomy Lumpectomy + RT | 6 years | 6 % 5 % | 66 % 70 % | 82% 79% |
| Van Dongen (1992) | 424 455 | Mastectomy Lumpectomy + RT | 6 ans | 9 % 15 % | - - | 73 % 71 % |
| Fischer (1995) | 589 628 634 | Mastectomy Lumpectomy+RT Lumpectomy | 12 ans | - 11 % 37 % | 50 % 49 % 47 % | 60 % 62 % 58 % |
Compilation of three large randomised trials demonstrating the equivalence of radical mastectomy (with lymphadenectomy) and single lumpectomy (with lymphadenectomy) followed by radiotherapy.
The absence of radiotherapy increases the number of local relapses without influencing the global survival.
Other examples
Several major surgical procedures have been reduced in relationship with efficient adjuvant therapies.
For instance, formerly, the presence of lumbo-aortic adenopathies in testicular cancer induced node excision with the risk of anejaculation. Nowadays this surgery is only proposed when persistent adenopathies exist after chemotherapy (and in certain cases when tissue is active according to PET-Scan). There is, therefore, a significant limitation in morbidity.
High Intensity Focused Ultrasound
Another to treat localized cancers by a pseudo-surgical method is the use of High Intensity Focused Ultrasounds.
Due to the high intensity a complete destruction of the glandular tissue due to coagulation necrosis is obtained, reaching the capsule and the periprostatic fat.
HIFU is nowadays mainly used for localized prostate cancer.
Tumour reduction surgery :
The most significant example is ovarian carcinoma.
Standard operative procedure for an ovarian carcinoma in a woman desiring no further pregnancies.
Surgical approach:Peritoneal cytology
- supra- sub-umbilical median incision to allow a complete inspection
Exploration of the peritoneal cavity and description of lesions
- either by sampling ascitis liquid
- or by peritoneal washings
Excision
- Side and size of ovarian tumour,
- Presence of tumour adherence,
- Spread to the pelvis (uterus, retro-rectal peritoneum),
- Spread to the submesocolic space (small intestine, mesentery, appendix, colon, omentum),
- Spread to supramesocolic space (liver surface, liver parenchyma, biliary ducts, stomach, pancreas, spleen, gastro-hepatic omentum, diaphragmatic peritoneum),
- Spread to parietal peritoneum,
- Study of the retro-peritoneal and lumboaortic nodes.
Surgical operative report
- Bilateral oophorectomy,
- Radical hysterectomy,
- Omentectomy,
- Appendicectomy,
- Retroperitoneal lymphadenectomy,
- Excision of the maximum number of peritoneal parietal or parenchymatous nodules whilst limiting intestinal resection: chemotherapy should begin less than one month after surgery with rapid postoperative recovery.
This complete surgical procedure is necessary to classify ovarian carcinoma and define a strategy for the upcoming adjuvant treatment.
- Precise description of tumours at opening of the cavity,
- Precise description of excisions,
- Precise description of location and size of residual tumours (after surgery).
Evaluation cancer surgery:
One of the most typical examples has been the 'second look laparotomy' in ovarian carcinoma. This procedure was systematically performed in order to evaluate the response to chemotherapy and to enable the conclusion of treatment. In reality, it has been demonstrated that such surgery did not modify patient survival (probably because currently available salvaging treatment is insufficient for modifying disease evolution). Second laparotomy is nowadays only performed within clinical trials.
A variant was defined for ovarian carcinoma with an initial incomplete surgical procedure. A second laparotomy is planned after 3 months’ chemotherapy in the hope to perform the complete excision of each tumour nodule.
Post chemotherapy lymphadenectomies are another example. They are performed in order to assess the absence of any viable residual tumour.
For instance, in testicular cancer presenting with voluminous lumboaortic masses and for which persistent node masses are revealed by scanner after 4 chemotherapy courses:
The lymphadenectomy will specify the state of the nodes:
- either simple fibrosis and necrosis,
- or benign transformation of a malignant dysembryoma into a benign teratoma,
- or the persistence of viable malignant tumours.
Nowadays, before practising such surgery, a Pet-Scan is performed. The first two cases do not show any FDG uptake (no viable tumour). FDG scintigraphy might avoid unnecessary surgery with its potential morbidity.
Relapse and metastasis surgery:
Surgery for relapse
Many relapse are unfortunately beyond any therapeutic proposals.However, occasionally, satisfactory or simply palliative excisions may be proposed when the tumour relapses after radiotherapy.
Some examples:
- for head and neck surgery (salvage total laryngectomy after conservative treatment),
- for certain gynaecological tumours treated by exclusive radiotherapy (total salvage pelvectomy with good quality excision is occasionally feasible),
- for breast carcinoma treated with lumpectomy: when late relapse occurs, a salvage mastectomy may be proposed.
Metastasis surgery
In the past, surgery was never performed on metastases.The occurrence of metastases in the first months or years after tumour excision generally signifies that the metastasis was already present at the time of surgery but was too small to be identified by usual methods.
Improved knowledge of the biology of cancer enables the proposed excision of metastases with a good chance of success:
A very good example is metastasis removal by partial hepatectomy for a unique colon carcinoma metastasis occurring several years after initial surgery. This (simple) procedure is often efficient enough to offer, without any other treatment, a long clinical remission with good quality of life.
- When the primitive tumour is stable or has disappeared,
- When the free interval between primitive tumour treatment and metastasis occurrence is long enough to prove a slow tumour progression (minimum two years),
- When the metastasis is unique (or with two to three metastases in the same location),
- When the surgical procedure is relatively simple and does not require a particularly large excision (one hepatic segment, one pulmonary lobe, one cerebral peripheral metastasis).
A noticeable exception might be the presence of multiple pulmonary metastases of a testicular teratocarcinoma matured through chemotherapy (no uptake with FDG scintigraphy) and which could relapse later.
All of these surgical procedures have a 'curative' intent (or at the very least they offer relief with good survival and quality of life).
Palliative surgery :
Surgery for osseous metastases
A pathological fracture (due to metastasis) will consolidate over a similar duration as for normal fractures, provided that the fracture is sufficiently immobilised.On the other hand, an osseous metastasis does not imply imminent patient death. However, it could imply considerable physical decline for the patient (bed immobilisation, risk of bedsores, dependency on the family circle, frustration faced with incapacity). Vigorous treatment is therefore of great help.
Rapid surgical repair of pathological fractures is therefore recommended when feasible and when it offers prompt patient mobilisation.
Some examples:
The presence of a prosthesis is not a contraindication for radiotherapy.
- femoral neck fracture (total hip prosthesis),
- fracture of femoral or humeral diaphysis (central medullar nail),
- vertebral collapse(corporeal cementoplasty).
When rachis metastases occur (osseous or meningeal metastases) with medullar compression (paraparesia or paraplegia), the ideal delay for surgical treatment is less than 24 hours. After 24 hours, vascular damage due to medullar compression renders possible movement recovery uncertain. Thus, the diagnosis of medullar compression should be treated as an emergency and the patient should immediately be referred to a surgeon for decompression and fixation. Complementary radiotherapy may also be useful.
If the delay is too long, then the patient will suffer from long painful and upsetting agony which could have been avoided (the patient’s death cannot be avoided however its dreadful conditions can).
Pre-fracture syndromes
The apparition of prefracture pains is another surgical emergency: the bone is damaged to such an extent that every movement is painful and the risk of complete fracture is very high. A surgical procedure for preventive consolidation could be associated with other measures such as localised radiotherapy or morphine treatment.
Derivation surgery
Derivation surgery may be carried out when the tumour becomes an obstacle either for respiratory, digestive or urinary tracts.Some examples:
The major psychological trauma consecutive to such a surgical procedures should be prevented via a clear and comprehensive explanation to the patient (and his/her family) of the remaining body function potential. These procedures should therefore not be performed too late (when body function damage is such that useful repair is no longer possible) or too early (before possible patient acceptance).
- tracheostomy (occasionally in emergency) for head and neck or thyroid cancers,
- colostomy for an occlusion in relation to digestive or ovarian tumours,
- gastrostomy to feed a patient with oesophageal or head and neck cancer,
- ureterostomy or other urinary diversion for bladder, prostate or gynaecological tumours,
- cranial shunts for intracranial hypertension.
Sometimes, tumour excision, even if it is not satisfactory in terms of survival, may be useful if involving uncomplicated postoperative recovery and requiring limited hospitalisation: the quantity of recurrence-free life and quality of life should be promoted.
Since they are more easily accepted by patients, it is also possible to carry out internal derivations:
The use of such prosthesis should therefore bring together various specialities in order to offer the most appropriate relief to patients: a clear evaluation of these methods by retrospective studies and quality of life questionnaires should be made in order to determine the most suitable solution.
- either via a surgical approach,
- or via a percutaneous approach,
- or by endoscopy,
- or by endovascular method.
The implantation of an oesophageal prosthesis using endoscopy, of an ureteral prosthesis by a percutaneous puncture or during cystoscopy, and the use of a colic prosthesis or a venous stent for protecting the patient from a superior cave syndrome are all very useful 'palliative surgical procedures'.
Surgery for cleanliness
A surgical procedure can also be proposed not to cure but to improve the patient's comfort.Tumour necrosis is very frequent around developed disease and, not only painful, its odour, bleeding and ugliness can also be very unpleasant for the patient and his/her family. Certain particularly neglected tumours have left us with horrifying pictures.
A simple excision can offer comfort and cleanliness: mastectomy, resection of an intestinal tumour despite hepatic metastases or derivation for fistulae.
Hormonal surgery
It consists in the ablation of an endocrine gland whose secretion is known to favour tumoral development.In practice only two locations are concerned: breast carcinoma (for which a surgical ovariectomy or pelvic irradiation may be proposed) or prostate carinoma (for which bilateral surgical castration may be proposed).
The psychological trauma for the patient should be prevented through thorough and attentive explanations.
However, most often, in order to avoid such explanations, the physician will prefer to treat medically (anti-hormone products: anti-androgens or anti-estrogens, chemical castration by a LH-RH analogue - see chapter on hormonotherapy). The results are identical although the cost is much higher.
Reconstruction surgery :
Most excision surgical procedures aim at preserving body functions as far as possible.
However, satisfactory cancer surgery involves a number of necessary mutilations.
Thus, reconstruction surgery becomes a very important phase in the rehabilitation of cured patients.
Occasionally, the reconstructive surgery can be carried out at the same time as the excision procedure:
In certain cases, reconstruction is delayed until the completion of adjuvant treatment:
- Restoring the digestive continuity (intestine, oesophagus),
- Reconstructing a functional bladder by enterocystoplasty immediately radical cystectomy
- Laryngeal reconstruction with immediate speech prosthesis
- Mammary reconstruction simultaneous as mastectomy,
- Testicular prosthesis simultaneous as orchidectomy,
- Ocular prosthesis immediately after enucleation.
Finally, certain reconstructions aim at repairing treatment sequelae
- Mammary reconstruction after adjuvant chemotherapy (and/or radiotherapy),
- Excision and osseous reconstruction after chemotherapy for a bone tumour
- Orbit or mandible reconstruction (Epithesis) after excision and radiotherapy of facial tumours.
The contribution of ortheses and prostheses, which are well adapted to the patient, together with vascular microsurgery techniques, and the use of free or pedicled flaps have all considerably increased the potential correction of deformities imposed by cancer or its treatment.
- Mandible reconstruction after osteoradionecrosis (see chapter on radiotherapy),
- Complex reconstruction after extensive Head and Neck surgery.
However, it should be clear that despite progress, the results are not a restitutio ad integrum. For this reason, and to avoid the disappointment induced by an imperfect result, many surgeons advise delaying mammary reconstruction until such times as all other treatments are concluded. Thus, all adjuvant treatments can be administered at full dose without paying attention to potential damage to the aesthetic surgery.
And finally, it should be clearly accepted that an imperfect result is always better than no correction at all.
Pain surgery :
Pain surgery is aimed at very specific situations when common analgesic treatment has no effect.
They are generally anaesthetic procedures carried out in a surgical theatre:
The irreversible sequelae of such procedures and their relative efficiency should induce surgeons to identify the indications of such treatment modalities through extensive discussion and consensus.
- Percutaneous neurostimulation,
- Medullar or intra-ventricular analgesia
- Regional nerve blocks (with local analgesic drugs or neurolytic agent),
- More rarely interruption neurosurgery (cordotomia, posterior root sections).
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