HC19: Surgical oncology

Challenges of cancer

In 2012, there where 14 million new cancer cases, 8 million cancer deaths and 33 million people living with cancer. These numbers will only increase. Even though surgeons aren’t the only doctors involved in cancer therapy, 80% of all solid cancers need surgery.

Surgical oncology has several challenges which need to be taken into account:

• Survival/cure
• Risk of recurrence
• Morbidity/mortality of treatment
• Quality of life/functionality
• Costs

There is an evolution in surgery from more invasive to less invasive.

Types of surgery

There are several types of surgical oncology:

• Curative
• Minimal invasive
• Acute
• Palliative
• Prophylactic

Curative surgery:

Curative surgery is an intervention with the aim of curing the disease. Several things happen:

• En-bloc resection: removal of the primary tumor and all the adjacent tissue which can contain micro-metastases
  • E.g. breast amputation + removal of the nearby lymph nodes
• No-touch technique: as little as possible has to be done with the tumor itself during its ejection → prevents tumor cells from detaching and metastasizing
  • This can be done with vasculature isolation → the vessels are isolated so the tumor cells can’t travel anywhere
• Clips: mark the site where the original tumor was → the radiation therapist knows where to provide additional therapy
• Rinsing the surgical field

Acute surgery:

There are 3 situations in cancer where acute surgery is necessary:

• Perforation
• Obstruction
• Bleeding

What kills first, has to be treated first. An example of this is the removal of a tumor which obstructs the colon → the tumor is removed to restore the normal function. Chances of cure in case of acute surgery are much lower than in normal, elective surgery.

Palliative surgery:

Palliative surgery is an intervention with the aim of easing the complaints of the patient. The chance of curation is 0%.

Palliative surgery may be useful to:

• Prevent obstruction → creation of a bypass
• Local control → excision

Complications of palliative surgery may be:

• Obstruction
• Fractures
• Seroma

Palliative surgery usually isn’t preformed on old and frail patients.

Prophylactic surgery:

Prophylactic surgery is preformed in the tissues where the main tumor often metastasizes in order to prevent further spread of the disease.

Debulking:

Debulking is the act of decreasing the number of tumor cells, and thereby removing the major part of the tumor load. This is applied in case of ovarian cancer and is usually followed by chemotherapy.

Resectability:

Resectability describes what kind of resection needs to be done:

• R0: radical resection of the tumor with no tumor cells left in the body
  • The best margin
• R1: macroscopically yes, but microscopically no
  • Microscopical irregularity is visible
• R2: residual tumor macroscopically in situ
  • During surgery, the surgeons are cutting through the tumor → residue is left behind

Less is more

In surgery, less is always more → less invasion leads to less morbidity.

This principle can be applied in mastectomy:

• Radical mastectomy: the whole breast is amputated
• Modified mastectomy: the breast tissue is amputated, but the pectoralis major remains in place
• Breast conserving mastectomy: only the tumor is removed, the rest of the breast is left in place

Locoregional control versus systemic disease

The difference between locoregional and systemic control is important:

• Locoregional control: in case of locoregional recurrences
  • Recurrence in the original site of the tumor is prevented, but not the metastasis in different tissues
  • Surgery, radiotherapy
• Systemic disease: in case of distant metastasis
  • Reaches the entire body → also prevents metastasis
  • Chemotherapy, hormonal therapy, targeted therapy

Intraoperative imaging:

Intraoperative imaging is used to visualize the tumors and remove the tumor more efficiently:

1. Fluorescence is given via a tube
2. The tumor cells light up → it becomes visible what has to be removed