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Surgical Treatment
Primary or Definitive Surgery
Once diagnosis and staging are complete a surgical oncologist, often with the help of a multidisciplinary tumour board discussion, must then determine the most appropriate initial treatment. The surgical procedure may involve anything form a simple surgical excision to an extremely complex radical resection.
Locoregional therapy involves resection of the primary tumour and, if necessary, the draining nodal basin. The primary surgery may require a conservative or radical approach. The decision to perform radical surgery has significant impact on the patient’s quality of life. Increasingly muti-modality approaches using neoadjuvant chemo or radiation therapy are allowing less radical operations to be performed with the SAME local control of disease. This results in the preservation of organs such as vocal cords, anus, breast or limb.
Cancer surgeries have unique considerations and concerns:
hemostasis and control of blood supply
expertise in minimizing luminal or peritoneal spread
tumour handling
avoiding incising the tumour itself
There is a demonstrable survival advantage for patients whose sarcomas, breast, rectal, gynecological or head and neck cancers are managed by surgeons with specific oncological training.
Cytoreduction
Cytoreduction, or debulking surgery is often not curative but may be of palliative benefit and may be offered in combination with other modalities.[1] This is performed if the surgical oncologist does not think all of the cancer can be removed. The goal is to reduce the volume of the primary tumour, or metastasis, in a situation where there is another effective treatment being considered for the possibility of long term survival. Debulking surgery offers benefits in some neuroendocrine tumours, ovarian cancers and intra-abdominal or retro-peritoneal sarcomas.
Metastasectomy
Metastasectomy is considered in highly selected populations, when the primary tumour has been controlled and there is evidence of limited spread to other organs. It is rarely curative but can be considered in the following isolated mets:
colon to liver (20-30% 5 year survival benefit)
sarcoma to lung
isolated brain met
Palliation
Palliative surgical procedures are not curative and are done to relieve significant symptoms. In considering palliative surgery the risks and benefits must be carefully weighed.
On occasion non-curative surgery can be of benefit to patients with symptoms and suffering related to advanced superficial nodal disease, fungating breast cancers, bowel or biliary obstruction, bleeding or pathological fracture.
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1. McCarter M, Fong Y. Role for Surgical Cytoreduction in Multimodality Treatments for cancer. Annals of Surgical Oncology. 2001;8:38-43. available online: http://www.annalssurgicaloncology.org/cgi/content/full/8/1/38 accessed March 22, 2008