Surgical Oncology: Its Basics
Surgery as a medical field has been changing rapidly since the late 1800s, in large part thanks to the development of safe and effective anaesthesia. Surgical oncology is a specialty that focuses on the surgical treatment of a variety of tumours’. Ephraim McDowell did the first reported resection of ovarian tumours in 1809, but as early as the 7th century, ancient Egyptians described techniques for removing breast tumours. Today, general surgeons can pursue additional training after their residency in the form of a surgical oncology fellowship. However, a surgeon does not have to do a surgical oncology fellowship in order to be a surgical oncologist. What is more common is that a surgeon who is trained in a particular body site may develop expertise in cancers of that site, and thus have experience in the multidisciplinary approach to the prevention, diagnosis, and treatment of those cancers. For example, a thoracic surgeon who is a surgical oncologist may devote most of his practice to lung cancer, while a head and neck surgical oncologist would be involved in treatment of cancers specific to his or her training, such as cancer of the larynx.
Why Surgical Oncology?
There are many cancers treated with surgery. In addition, there are many types of treatments that can be applied to cancer patients. Surgical treatment depends upon the type of cancer, how advanced it is, where it is located in the body, and more. The best approach for some patients may be chemotherapy, radiation, surgery, or a combination of methods. Our multidisciplinary team of oncologists tailors the treatment recommendation using evidence-based guidelines in order to provide the best possible outcome.
The surgeons at UT MIST perform operations covering the following disease sites:
- oesophageal cancer
- gastric tumours and cancer: gastrointestinal stromal tumours, gastric neuroendocrine tumours, gastric cancer
- liver/bile duct cancer: hepatocellular carcinoma, cholangiocarcinoma, choledochal cyst, colorectal liver metastases
- pancreas tumours and cancer: benign pancreatic tumours, intraductal papillary mutinous neoplasm, pancreatic cancer and pseudo cysts
- colorectal cancer: appendiceal masses, colon cancer, rectal cancer
- endocrine/adrenal: thyroid masses, thyroid cancer, parathyroid diseases, adrenal masses
- melanoma/sarcoma: soft tissue tumours and skin cancers
- breast cancer
Although cancer surgery can be effective, prevention and early detection remain the best defences against cancer.
Cancer has become a medical specialty warranting its own surgical area because of advances in the biology, path physiology, diagnostics, and staging of malignant tumours. Surgeons have traditionally treated cancer patients with resection and radical surgeries of tumours, and left the management of the cancer and the patient to other specialists. Advances in the early diagnosis of cancer, the staging of tumours, microscopic analyses of cells, and increased understanding of cancer biology have broadened the range of nonsurgical cancer treatments. These treatments include systematic chemotherapy, hormonal therapy, and radiotherapy as alternatives or adjunctive therapy for patients with cancer.
Not all cancer tumours are manageable by surgery, nor does the removal of some tumours or metastases necessarily lead to a cure or longer life. The oncological surgeon looks for the relationship between tumours excision and the risk presented by the primary tumour. He or she is knowledgeable about patient management with more conservative procedures than the traditional excision or resection.
According to the American Association of Cancer Registries, the most commonly diagnosed cancers for males in the United States during 1995–1999, with total of over 1.7 million cases for all races, were:
- prostate–28.6%
- lung–16.3%
- colon and rectum–11.7%
- bladder–6.6%
- non-Hodgkin’s lymphoma 4.2%
White males make up more than 1.4 million of the total prostate cancer cases, with African Americans and Hispanic Americans accounting for 160,356 and 75,237 cases respectively. Each of the latter groups had higher stomach cancer incidence in the top five lists, replacing non-Hodgkin’s lymphoma. For women, the total cases for all races was over 1.6 million, and white women made up more than 1.4 million of this number. There were 140,888 female African American cases and 76,810 Hispanic American female cases.
Leading cancers for all groups were:
- breast–30.7%
- lung–12.5%
- colon & rectum–12.2%
- corpus & uterus–5.9%
- ovary–3.9%
Role of Surgery
Surgery is the oldest form of cancer treatment, and for most patients, part of the curative plan includes surgery. The most important part of the consultation with the surgeon is a complete history and physical exam. Before surgical resection, diagnostic and staging studies should be performed. This helps the surgeon determine if the cancer is resectable (removable with surgery), and allows him or her to plan the surgical approach. Due to improved screening techniques, many patients have disease that is curable with surgery alone at diagnosis. In such cases, after surgery, the patient’s follow-up care includes close observation and/or radiology and lab tests.
Procedures
Excision
Local excision has been the hallmark of surgical oncology. Excision refers to the removal of the cancer and its effects. Resection of a tumor in the colon can end the effects of obstruction, for instance, or removal of a breast carcinoma can stop the cancer. Resection of a primary tumor also stops the tumor from spreading throughout the body. The cancer’s spread into other body systems, however, usually occurs before a local removal, giving resection little bearing upon cells that have already escaped the primary tumor. Advances in oncology through path physiology, staging, and biopsy offer a new diagnostic role to the surgeon using excision. These advances provide simple diagnostic information about size, grade, and extent of the tumor, as well as more sophisticated evaluations of the cancer’s biochemical and hormonal features.
Regional lymph node removal
Lymph node involvement provides surgical oncologists with major diagnostic information. The sentinel node biopsy is superior to any biological test in terms of prediction of cancer mortality rates. Nodal biopsy offers very precise information about the extent and type of invasive effects of the primary tumour. The removal of nodes, however, may present pain and other morbid conditions for the patient.
Local and regional recurrence
Radical procedures in surgical oncology for local and regional occurrences of a primary tumor provide crucial information on the spread of cancer and prognostic outcomes. However, they do not contribute substantially to the outcome of the cancer. According to most surgical oncology literature, the ability to remove a local recurrence must be balanced by the patient’s goals related to aesthetic and pain control concerns. Historically, more radical procedures have not improved the chances for survival.
Surgery for distant metastases
In general, a cancer tumour that spreads further from its primary site is less likely to be controlled by surgery. According to research, except for a few instances where a metastasis is confined, surgical removal of a distant metastasis is not warranted. Since the rapidity of discovering a distant metastasis has little bearing upon cancer survival, the usefulness of surgery is not time-dependent. In the case of liver metastasis, for example, a cure is related to the path physiology of the original cancer and level of cancer antigen in the liver rather than the size or time of discovery. While surgery of metastatic cancer may not increase life, there may be indications for it such as pain relief, obstruction removal, control of bleeding, and resolution of infection.
Preparation
Surgery removes cancer cells and surrounding tissues. It is often combined with radiation therapy and chemotherapy. It is important for the patient to meet with the surgical oncologist to talk about the procedure and begin preparations for surgery. Oncological surgery may be performed to biopsy a suspicious site for malignant cells or tumor. It is also used for tumor removal from such organs as the tongue, throat, lung, stomach, intestines, colon, bladder, ovary, and prostate. Tumors of limbs, ligaments, and tendons may also be treated with surgery. In many cases, the biopsy and surgery to remove the cancer cells or tissues are done at the same time as the biopsy.
The impact of a surgical procedure depends upon the diagnosis and the area of the body that is to be treated by surgery. Many cancer surgeries involve major organs and require open abdominal surgery, which is the most extensive type of surgical procedure. This surgery requires medical tests and work-ups to judge the health of the patient prior to surgery, and to make decisions about adjunctive procedures like radiation or chemotherapy. Preparation for cancer surgery requires psychological readiness for a hospital stay, postoperative pain, sometimes slow recovery, and anticipation of complications from tumor excision or resection. It also may require consultation with stomal therapists if a section of the urinary tract or bowel is to be removed and replaced with an outside reservoir or conduit called an ostomy.
Risk
The type of risks that cancer surgery presents depends almost entirely upon the part of the body being biopsied or excised. Risks of surgery can be great when major organs are involved, such as the gastrointestinal system or the brain. These risks are usually discussed explicitly when surgerical decisions are made.
Results
Most cancers are staged; that is, they are described by their likelihood of being contained, spreading at the original site, or recurring or invading other bodily systems. The prognosis after surgery depends upon the stage of the disease, and the pathology results on the type of cancer cell involved. General results of cancer surgery depend in large part on norms of success based upon the study of groups of patients with the same diagnosis. The results are often stated in percentages of the chance of cancer recurrence or its spread after surgery. After five disease-free years, patients are usually considered cured. This is because the recurrence rates decline drastically after five years. The benchmark is based upon the percentage of people known to reach the fifth year after surgery with no recurrence or spread of the primary tumour.
Alternatives to cancer surgery exist for almost every cancer now treated in the United States. Research has been very successful for some—but not all—cancers. There are many alternatives to surgery, and chemotherapy and radiation after surgery. Most organizations dealing with cancer patients suggest alternative treatments. Physicians and surgeons expect to be asked about alternatives to surgery, and are usually quite knowledgeable about their use as cancer treatments or as adjuncts to surgery.
After Surgery
After surgery, the type and duration of side effects and the elements of recovery depend on where in the body the surgery was performed and the patient’s general health. Some surgeries may alter basic functions in the urinary or gastrointestinal systems. Recovering full use of function takes time and patience. Surgeries that remove such conduits as the colon, intestines, or urinary tract require appliances for urine and faecal waste and the help of a stoma therapist. Breast or prostate surgeries yield concerns about cosmetic appearance and intimate activities. For most cancer surgeries, basic functions like tasting, eating, drinking, breathing, moving, urinating, defecating, or neurological ability may be changed in the short-term. Resources to attend to deficits in daily activities need to be set up before surgery.