Surgery is a common treatment for many conditions or pathologies, and this is particularly true in the treatment of cancer.
Cancer surgery is most often used for curative purposes, i.e. to remove the cancerous tumor. However, there are other types of surgical treatments or intervention.
The general modalities of cancer surgery do not substantially differ from surgery in any other context. Surgery should always be performed by an experienced surgeon; specific expertise is often required for rare tumors. There are different types of surgery that can be used at different stages of the disease:
The objective is to diagnose cancer by the biopsy, or tissue sample, of the tumor cells. It is a relatively simple, straightforward method for the exploration of the tumor environment to determine the stage of the disease (e.g. exploratory coelioscopy in ovarian cancer).
In some instances, a diagnostic procedure can result in curative surgery.
Curative surgery is a potential option only when the cancer is sufficiently localized. Indeed, when the cancer is advanced to the point where remote metastases (tumor cells are circulating in the blood) are present, surgery is not an effective curative option. For this reason, a so-called ‘disease extension assessment’ must be performed before performing a curative surgery procedure. If performed, this procedure consists of the total removal of the tumor to safety margins so that no tumor tissue is visible to the naked eye. If the margins around the tumor are healthy, the resection is referred to as R0. It may nevertheless happen that these edges are microscopically contaminated by cancer after anatomopathological examination. In such instances, the resection is referred to as R1. It is then possible to propose a resection of the periphery tissues until only healthy tissue is present. Finally, it is not possible to achieve the complete removal of the tumor. In which case, a macroscopic residue remains, or an R2 resection.
With preoperative imaging, the goal is to avoid an R2 outcome which is a considered failure of radical curative surgery. In addition to tumor removal, it is often necessary to analyze the lymph nodes that drain the tumor site. Indeed, these nodes are the first ‘communicators’ of the existence tumor cells prior to their dissemination to other organs.
Lymph node dissection which consists of removing the entire chain of lymph nodes and subsequently analyzing the removed tissue. If the lymph nodes have been compromised, additional treatment will be recommended (e.g., radiotherapy and / or chemotherapy.)
A sentinel node procedure,which is a less invasive technique. The surgeon first injects a marker to identify the first node(s) that relay between the tumor and the patient’s general circulatory system. These nodes are removed and analyzed on site by the pathologist as an extemporaneous examination.If the lymph nodes are compromised, a complete dissection is performed. Otherwise, the rest of the ganglion chain is left in place.
Noted previously that cancer surgery should only be performed if it is certain to remove all the tumor mass. However, in rare cases (damage to the peritoneum in particular), it has been shown that a maximum but incomplete resection can deliver a benefit in survival when coordinated with additional treatment, and in particular chemotherapy. The indication for such a treatment plan must be validated in the RCP.
Similarly, exceptions are possible in the event of metastatic (spreading) disease.
If metastases are present from the outset but few (oligometastatic disease: 1 to 3 or even 5 secondary lesions maximum), surgery may be proposed for the initial tumor and related metastases if all are accessible to curative surgery with sufficient safety margins. Additional treatment (chemotherapy, radiotherapy) may be necessary.
If metastases appear later and are again few, surgery may be an acceptable option. Its indication must be discussed in the RCP in relation to other possible focal treatments: stereotaxic radiotherapy, interventional radiology (e.g., radiofrequency, cryoablation, etc.).
This approach is considered without the goal of eliminating the cancer and thus curing the patient, but instead to reduce the pain or other significant symptoms (e.g. a painful mass, skin complications such as bleeding or infections, etc.)
One or more procedures that designed to eliminate the possibility of the cancer before it appears. There are hereditary genetic predisposition syndromes that expose the patient to an increased risk of cancer (e.g., BRCA 1 and 2 mutations that are responsible for breast and ovarian cancer.)
When a significant risk is established, such as with a mutation identified by a validated test prescribed by an oncogeneticist, preventive surgery may be proposed. For example, in the case of BRCA mutations, this might include double mastectomy and/or adnexectomy(i.e. removal of breasts and ovaries.) This approach is done in close consultation with the patient because the benefit / risk ratio is less obvious than in the case of a diagnosed cancer, and the consequences can be serious and longstanding (e.g., infertility, operative risk, etc.).
Finally, reconstructive surgery addresses not the cancer but rather focuses on the complications of its treatment. Such procedures aim to restore self-image, as well as repair aesthetic and functional damage. These can be performed in a single session, as when the tumor is removed, or subsequently by a specialized practitioner.
The side effects of cancer surgery
are the same as any surgical intervention, including:
It is important to note that healing disorders may be more frequent if chemotherapy and / or radiotherapy have been performed before.
The indication for surgery should be discussed by the MDTB (multidisciplinary tumor board)which brings together the entire team of oncology professionals: oncologists, surgeons, radiotherapists, radiologists, etc.
Any surgery plan will be validated, but it will also be considered within the overall therapeutic strategy that may include a host of non-surgical options such as chemotherapy, radiotherapy, hormone therapy, immunotherapy, as well as other new and innovative treatments.
Neo-adjuvant treatment (chemotherapy) may precede and adjuvant treatment may follow
(chemotherapy and/or radiotherapy and/or hormone therapy and/or immunotherapy etc).
