Resection of isolated metastatic lesions is useful for a selected group of patients in certain cancers (Box 2.1). In general this is undertaken for patients with surgically resectable metastatic disease at presentation or in a very select group of patients with good performance status with a long disease-free survival after treatment of the primary tumour. In the absence of proper randomized studies it is not known whether the observed therapeutic benefit is actual or due to the strict selection process (selection bias). The common situations are resection of isolated or limited liver metastases in colorectal cancer which results in 20–40% 5-year survival (p. 164). Pulmonary metastatectomy in sarcomas leads to a 5-year survival of 20–25% (p. 259). An alternative is the evolving use of radiofrequency ablation.

Box 2.1
Role of metastatectomy

• Liver – selected patients with colorectal cancer.

• Lung – selected patients with colorectal, kidney and testicular cancers and sarcoma.

• Adrenal – selected patients with resectable lung cancer and isolated adrenal disease.

• Brain – solitary metastasis with controlled/potentially curable systemic disease.

Salvage surgery

Surgery is useful as a salvage measure after primary treatment failure or recurrence after definitive treatment. It is only appropriate for fit patients with a good chance of prolonged survival. Examples include abdomino-perineal resection after chemoradiotherapy for anal cancer, and exenteration in cervical cancer after chemoradiotherapy. In patients with prior limited surgery or chemoradiotherapy, a second chance of cure is aimed with surgery. Examples include mastectomy for local recurrence after conservative surgery for breast cancer and neck node dissection for isolated nodal recurrence after chemoradiotherapy for head and neck cancer.

Palliative surgery

The aim of palliative surgery is to improve or prevent significant symptoms (e.g. pain, bleeding and obstruction) which are likely to occur without intervention. It can also enhance the effect of chemotherapy (e.g. in ovarian cancer where it improves survival). Debulking surgery of the primary tumour can produce good symptom control and improve quality of life by preventing complications due to uncontrolled disease (e.g. loco-regional surgery in breast cancer prevents fungation and symptomatic axillary disease).

Reconstructive (oncoplastic) surgery

Extensive resection often results in disruption of normal anatomy and subsequent cosmesis and function. Plastic surgical techniques are useful in correcting the anatomical defects and improving cosmesis (e.g. reconstructive breast surgery) and function (e.g. in head and neck surgery).

Risk reduction surgery

Less than 5% patients have a genetic component to their cancer (p. 45). Increasing understanding of the development of genetically associated cancers has led to prophylactic surgery for some patients. Box 2.2 shows the indications for common prophylactic surgeries. Appropriate genetic testing and counselling is, however, an absolute pre-requisite prior to any prophylactic surgery. Women with BRCA1 and BRCA2 mutations have a high risk of breast cancer which is reduced by 90–95% with bilateral mastectomy. However, the decision to undergo prophylactic mastectomy should be done after careful discussion on explaining the future quality of life, potential surgical risks and wishes of the patient. Alternative risk reduction methods such as use of tamoxifen and prophylactic oophorectomy after completion of family should also be considered. Another example is FAP and prophylactic colectomy (p. 50).

Box 2.2
Potential indications for risk reducing surgery