SURGICAL MANAGEMENT OF CANCER

SURGICAL MANAGEMENT OF CANCER

Can be divided into
  
surgical  treatment of primary tumour

surgical treatment of the regional lymph node basin

  surgical treatment of distant metastasis

Although surgery is the most effective therapy for most solid tumors most patients die of metastatic diseases

Therefore to improve patient survival rates a multimodality approach with systemic therapy­
and radiation therapy is key for most tumors. It is important
that surgeons involved in cancer care know not only how to perform a cancer operation but also the alternatives to surgery and he well versed in reconstructive options

 

It is also crucial that the surgeon be familiar with the indications for and complications of preoperative and postoperative chemotherapy and radiation therapy

Although the surgeon will not be delivering these other therapies, as the first physician to see a patient with a cancer diagnosis. he or she is ultimately responsible for initiating the appropriate consul­tations

 As such the surgeon often is responsible for determining the most appropriate adjuvant therapy for a given patient. as well as the best sequence for therapy

In most instances. a multidisciplinary approach beginning at the patient's initial presentation is likely to yield the best result

Surgical Management of Primary Tumors 

The goal of surgical therapy for cancer is to achieve oncologic cure

A curative operation presupposes that the tumor is confined to the organ of origin, or to the organ and the regional lymph node basin

Patients in whom the primary tumor is not resectable with negative surgical margins are considered to have inoperable disease

The operability of primary tumors is best determined before surgery with appropriate Imaging studies that can define the extent of local­ regional disease

 For example, a preoperative thin-section CT scan is obtained to determine resectability for pancreatic cancer, which is based on the absence of extrapancreatic disease, the absence of tumor extension to the superior mesenteric artery and celiac axis, and a patent superior mesenteric vein-portal vein confluence

 Disease involving multiple distant metastases is deemed inoperable since it is usually not curable with surgery of the primary tumor

 Therefore patients who are at high risk of having distant metastasis should have a staging work-up prior to surgery for their primary tumor

 On occasion, primary tumors are resected in these patients for palliative reasons, such as improving the quality of life by alleviating pain infection, or bleeding

An example of this is toilet mastectomies for large ulcerated breast tumors

 Patients with limited metastases from a primary tumor on occasion are considered surgical candidates if the natural history of isolated distant metastases for that cancer type is favorable, or the potential complications associated with leaving the primary tumor intact are significant

In the past it was presumed that the more radical the surgery
the better the oncologic outcome would be. but now this has been recognized as not necessarily being true, leading to more conservative operations, with wide local excisions replacing compartmental resections of sarcomas; and partial mastectomies, skin-sparing mastectomies, and breast conserving therapies replac­ing radical mastectomies for breast cancer

 The uniform goal for all successful oncologic operations seems to be achieving widely negative margins with no evidence of macroscopic or microscopic tumor at the surgical margins

 For example, positive surgical mar­gins have been shown to be a predictor of systemic recurrence and poor disease-specific survival rates after breast-conserving therapy for invasive breast cancer This may be because the residual tumor at the primary tumor site is a source for systemic

spread of the tumor besides increasing the risk of local recurrence of the tumor

 The importance of negative surgical margins for local tumor control and/or survival has been documented repeatedly for several other tumor types, including sarcoma. pancreatic cancer, and rectal cancer it is clear that every effort should be made to achieve microscopically negative surgical margins. Inking of the margins orientation of the specimen by the surgeon, and immedi­ate gross evaluation of the margins by the pathologist with frozen section analysis where necessary may assist in achieving negative margins at the first operation

 In the end, although radiation therapy and systemic therapy can assist in decreasing local recurrence rates in the setting of positive margins, adjuvant therapy cannot substitute for adequate surgery.

Although it is clear that the surgical gold standard is negative
surgical margins, the appropriate surgical margins for optimal lo­cal control are controversial for most cancer types

 In most tumors, cancer cells are thought to extend several millimeters beyond the gross tumor

Furthemore, histologic margin analysis is thought to be susceptible to some sampling error

For some cancer types such as breast cancer, patients who have close surgical margins have been demonstrated to have a higher local recurrence rate than patients who had widely negative margins

Even in breast cancer, however, the optimal margin width remains controversial

 This may be in part because endorsing a certain clear margin distance would sug­gest that mastectomy should be performed in patients in whom that width could not be achieved with breast conserving surgery, even though negative margins were achieved

In contrast, in melanoma the optimal margin width for any tumor depth has been defined , it is important to determine optimum surgical margins for each cancer type so that adjuvant radiation and systemic therapy can be offered to patients deemed to be

tags:management,cancer,surgical