Your cancer

Living with the disease

Cancer Surgery

What is it ?

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.

Use

The general modalities of cancer surgery do not differ substantially from surgery in any other context.
Nevertheless, it should be performed by a surgeon who has experience in the field. And in instances with rare tumors, specific expertise is often required.
Surgery is a treatment that can be used at different stages of cancer disease, and there are different types of surgery :

Diagnostic surgery

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

Surgery is only useful when the cancer is localized. Indeed, when the cancer is at an advanced stage with distant metastases, it means that the tumor cells are circulating in the blood, so it is not always essential to perform a carcinological surgery. This is why a so-called extension workup of the disease must be performed before a carcinological surgery is validated. Curative surgery consists in the total removal of the tumor by taking safety margins that do not contain any tumor visible to the naked eye. If the margins are healthy, the resection is said to be R0. However, it may happen that these margins are microscopically contaminated by cancer after anatomopathological examination: this is called R1 resection. It may then be proposed that these margins be resected until they are in healthy tissue. Finally, it is possible to fail to remove the tumor in its entirety, a macroscopic residue is therefore left in place: R2 resection. The objective of preoperative imaging is to avoid this situation, which is a failure of carcinological 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.
Two removal techniques are possible :

Lymph node dissection which consists of removing the entire chain of lymph nodes and subsequently analyzing the removed tissue. It is typical to include complementary treatment with the surgical procedure if the lymph nodes have been compromised. (e.g., radiotherapy and / or chemotherapy.).

A sentinel node procedurewhich 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.

Cytoreduction surgery

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 MDBT (multidisciplinary tumor board).

Surgery for metastases

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.), and eventually complete with a chemotherapy.

Palliative surgery

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.).

Prophylactic surgery

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.).

Reconstructive surgery

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.

Side Effects

The undesirable effects of surgery in oncology
are like those inherent in any surgical intervention :

Anesthetic risk

Infection of the operating site

Healing disorders

It is also important to note that healing disorders may be more frequent if chemotherapy and / or radiotherapy have been performed before.

Residual pain

Indications

The indication for surgery is discussed in the MDBT (multidisciplinary tumor board) that 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.