Principles of surgical oncology

Published on 09/04/2015 by admin

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Last modified 09/04/2015

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2 Principles of surgical oncology

TV. Ajithkumar

Introduction

Surgery remains the major mode of cure for many cancers. The majority of solid tumours are treated initially with a curative resection if possible. The proportion of patients who can undergo a curative resection depends on the stage at presentation and tumour site. Curative surgery may result in disruption of cosmesis and function. Hence surgery also has an important role in reconstructive surgery to maintain body image and ability to return to normal functioning life.

The potential role of surgery in the management of cancer includes:

• Diagnosis and staging.
• Curative.
• Palliative.
• Reconstructive (oncoplastic) surgery.
• Risk reduction surgery.
• Minimal access and robotic.

Diagnosis and staging

Diagnosis

Histological diagnosis is obtained from tumour tissue by fine needle aspiration cytology, core biopsy, incisional biopsy and excisional biopsy. Choosing the right technique is based on the location of tumour, anticipated type of the tumour and reliability of the method to make a definite diagnosis.

Fine needle aspiration (FNA) yields quick result and shows cellular characteristics but not architecture. FNA serves as good screening tool prior to more definitive diagnostic methods. FNA is useful for diagnosis of enlarged lymph nodes, aspiration of cysts, diagnosis of thyroid nodule and confirmation of recurrent or metastatic disease.

Core biopsy helps to visualize architecture as well as to perform immunohistochemical studies. It is useful in the diagnosis of solid masses such as breast lumps or liver metastases. However, core biopsy should not be used in lymphoma (which requires extensive immunohistochemical stains) or for soft tissue or bone sarcoma.

Incisional biopsy is used when core biopsy is non-diagnostic and excision biopsy is not appropriate. The common indication is a suspected sarcoma needing neoadjuvant treatment or definite resection. Care should be taken when planning incision biopsy to ensure that the site of biopsy is within the area definite surgery and should only be undertaken by surgeons who will undertake the final surgery. A poorly planned incision biopsy can lead to unnecessary morbid surgery.

Excision biopsy involves removal of the entire mass or skin lesion. It is important to make sure that this procedure does not compromise a later wider excision if necessary. The specimen needs to be oriented in three dimensions for the pathologist to determine surgical margins.

Frozen section is occasionally used preoperatively to confirm diagnosis when previous histologic diagnosis is not available (e.g. solitary lung lesions), to decide need for further surgery (e.g. lymph node dissection) and ensure adequate surgical margins.

Staging

Various surgical procedures such as endoscopy and staging laparotomy aid in defining the extent of disease as well as obtaining histological confirmation of metastatic disease. These are covered in detail for specific malignancies. One example is the use of laparoscopy as an adjunct to detect small peritoneal and liver metastases reduces the number of ‘open and close’ laparotomies by less than 5% in stomach cancer.

Curative surgery

Surgery plays a significant role in curative treatment of cancer. For many cancers surgery is the primary modality of treatment. A decision regarding curative surgery is made after careful consideration of various patient and tumour related characteristics at a multidisciplinary meeting with surgeons, oncologists, radiologists and pathologists. At this meeting staging and diagnosis will be reviewed along with information concerning the patient. Patient-related factors which influence the choice of curative surgery include age, performance status and co-morbidities. Tumour-related factors include chances of long-term benefit and potential surgical risks and complications.

Surgery of the primary tumour

Curative surgery is aimed at removal of the malignant tumour with a clear margin of normal tissue (‘R0’ resection) with reconstruction of the surgical defect if appropriate. Based on the extent of removal of cancer, resections are classified as follows which is part of the TNM staging:

• R0 – all margins are histologically free of tumour.
• R1 – microscopic residual disease after resection.
• R2 – gross residual disease after resection.
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