- Email: [email protected]
Principles of surgery for tumors
C H A P T E R
12 Principles of surgery for tumors O U T L I N E 12.1 Preoperative considerations 340 12.1.1 Review of clinical features, imaging, and comorbidities 340 12.1.2 Informed consent 340 12.1.3 Facilities 340 12.2 Classification of operations 340 12.2.1 Biopsies for diagnosis 340 12.2.2 Biopsies for staging: sentinel node biopsy 341 (a) General 341 (b) Sentinel node biopsies in the treatment of carcinoma of the breast 341 (c) Sentinel node biopsies in the treatment of malignant melanoma 341 12.2.3 Removal of the primary tumor 342 12.2.4 After neoadjuvant chemotherapy and radiotherapy 342 12.2.5 Palliative procedures: “debulking,” removal of local recurrences, and removal of metastases 343 (a) “Debulking”/“cytoreductive” operations 343 (b) Removal of local recurrences 343 12.2.6 Other 344
Principles of Tumors https://doi.org/10.1016/B978-0-12-816920-9.00012-2
(a) For relief of specific complications (b) Reconstruction (c) Prophylactic
344 344 344
12.3 Aspects of particular cancer operations and their complications 345 12.3.1 Lung 346 (a) Biopsies 346 (b) Resections 346 12.3.2 Colon and rectum 346 (a) Biopsies 346 (b) Resections 346 12.3.3 Breast 348 (a) Biopsies 348 (b) Resection 348 12.3.4 Prostate 349 (a) Biopsies 349 (b) Resections 350 12.3.5 Other 350 12.4 “Robotic” surgery 12.4.1 Background 12.4.2 Advantages and disadvantages
350 350 350
12.5 Translational notes on surgery in cases of cancer 351 References
339
352
Copyright © 2020 Elsevier Inc. All rights reserved.
340
12. Principles of surgery for tumors
Surgery is the mainstay of treatment of primary solid tumors and, to a lesser extent, secondary tumors. Extensive removal of organs became possible in the late 19th century, with technical advances in anesthesia and antisepsis, and later in the support services, especially blood transfusion. This chapter gives an overview of current surgical therapies for tumors.
components are described in US government guidelines [5] and can be summarized: (i) Reasons/benefits of the proposed surgery, (ii) Description of and risks of the proposed surgery and anesthesia to be used, (iii) Pros and cons of no treatment and treatment alternatives, (iv) Qualifications, experience, and credentials for their roles in the operation, of all persons involved in the surgery and postoperative care.
12.1 Preoperative considerations 12.1.1 Review of clinical features, imaging, and comorbidities When referred a patient who has a tumor which may be treatable by surgery, the surgeon assesses all aspects of the case: Is the diagnosis correct? What is the stage of the tumor? Can the tumor be resected? Will the benefits of the operation outweigh the complications of the surgery? The anesthetist and the surgeon together consider the additional questions: is the patient physically fit for the operation? Are there any contravening comorbidities or drug therapies? For this, all the clinical features of the case, as well as all the diagnostic imaging and other tests, are reviewed and supplemented when necessary. The next step is to select the optimum technique to achieve the objective of the surgery with minimum disturbance to normal tissues. This concept is usually referred to as using “minimally invasive” techniques [1,2]. In general, minimally invasive surgery is associated with less pain, a shorter hospital stay, and fewer complications [3].
12.1.2 Informed consent Informed consent is an important aspect of surgery because outcomes may not measure up to patients’ expectations [4]. The essential
12.1.3 Facilities With current pressures on medical resources, the surgeon and anesthetist also have to decide on which conditions are safe for the operation to be carried out. The options may include (i) full-support operating theaters, (ii) ambulatory conditions, usually involving short-duration general an anesthetic or sedation, and (iii) outpatient conditions when a local anesthetic is sufficient. The selection of facility is determined by the kind of operation contemplated [6,7].
12.2 Classification of operations Surgical procedures can be required at all phases in the treatment of a tumor.
12.2.1 Biopsies for diagnosis These include aspiration and core needle biopsies. When an incisional or excisional procedure follows the needle biopsy, the needle track of the previous biopsy should be removed in continuity. If any follow-up treatment especially radiotherapy is envisaged, anatomical markers, for example, radio-opaque clips, should be placed in the biopsy bed.
12.2 Classification of operations
12.2.2 Biopsies for staging: sentinel node biopsy (a) General According to the various staging protocols (see in Chapter 10), the detection of any remote deposit of tumor automatically classifies the case as M1 or higher in the TNM system (see in Section 10.4). Thus, if in the work-up of a case of apparent local tumor only, imaging demonstrates a suspicious lesion remote from the primary, a biopsy may be undertaken to determine its nature. If tumor is demonstrated, the stage is changed to “4” and the patient’s treatment may be significantly altered. This issue can arise in relation to any tumor type which is capable of metastasis. (b) Sentinel node biopsies in the treatment of carcinoma of the breast Staging biopsies to assist choice of operation is particularly relevant to carcinoma of the breast. In this disease, spread to axillary lymph nodes (N1-x in the TNM system) is common, and of great prognostic importance. Currently, imaging by ultrasound is usually routine, and any abnormal node is either biopsied by needle aspiration or removed. If, however, there is no abnormal node by ultrasound, it is important to determine if any small deposits are present in the axillary nodes. Complete axillary lymph node removal has significant side effects, especially chronic lymphedema of the arm. However, selective sampling of the node most likely to be the site of a small metastasis can be done. The procedure known as “sentinel node biopsy” is based on the assumption that if that first node (the “sentinel node”) has no tumor in it, then the other axillary nodes are unlikely to have tumor in them. The technical steps in identifying the “sentinel nodes” in a patient involve injecting the breast with a dye, which passes via lymphatic vessels to stain the lymph nodes in the axilla. The lowest node containing dye at exploration of the axilla is the sentinel node.
341
Current recommendations are that sentinel node biopsy should be performed on all early breast cancers, whether or not the nodes are abnormal by imaging. This includes patients with DCIS only on breast biopsy [8]. The primary assumptiondthat tumor cells pass to the anatomically lowest node in the axilla firstd might be questioned because the small lymphatic vessels in the breast and axilladas in most parts of the bodydare plexuses, and transiting cells have the opportunity to bypass any particular, or in fact, possibly all, local lymph nodes. This is supported by the findings that 1%e5% of patients who have had a sentinel node biopsy with no tumor found suffer subsequent tumor growths in their axillae [9]. The long-term outcome for patients who are sentinel node negative without axillary clearance but who developed local recurrence is not less than those who had axillary clearance. This is presumably because tumor cells spread via nonaxillary lymphaticsde.g., in the chest walldas well as through blood capillaries to the remainder of the body. The whole topic was considered in a recent Cochrane Review [10] concluding This review confirms the benefit of SLNB and axillary sampling as alternatives to ALND for axillary staging, supporting the view that ALND of the clinically and radiologically uninvolved axilla is no longer acceptable practice in people with breast cancer.
(c) Sentinel node biopsies in the treatment of malignant melanoma The principle described above for breast cancer has been applied to malignant melanoma. Melanomas, however, are probably more likely than carcinomas to spread via the blood stream, and so the rationale for this application may be weakened. Sentinel node biopsy can be done only for melanomas of the arms, legs, or head and neck. It is controversial because of the complications (especially permanent lymphedema) and the availability of nonsurgical prognostic markersdgenetic profiles [11e14].
342
12. Principles of surgery for tumors
A Cochrane review in 2015 concluded Currently this evidence is not sufficient to document a benefit of SLNB when compared to observation in individuals with primary localised cutaneous melanoma [15].
12.2.3 Removal of the primary tumor After diagnosis and staging of a particular tumor, surgical resection is usually undertaken if there is a reasonable zone of normal tissue at the edge of the tumor. If there is any uncertainty, a frozen section of the margin can be carried out. Margins should be as wide as possible. Recommendations are arbitrary. In all the following operations, if intraarterial chemotherapy is to be used, catheters can be inserted during the operation.
Notes on particular primary operative removals are given below (Figs. 12.1 and 12.2).
12.2.4 After neoadjuvant chemotherapy and radiotherapy Generally, prior treatment with chemotherapy (“neoadjuvant chemotherapy”) makes operative removal easier [16]. In contrast, preoperative radiotherapy causes devascularization and fibrosis of tissues, so that the ability to heal the wound is reduced. Some of the complications that make surgery in irradiated tissue more difficult or hazardous are the following: (i) Infection; (ii) poor wound healing; (iii) slough; (iv) exposure of tendons, bone, or other important structures; (v) difficult hemostasis and or secondary hemorrhage;
No micro-metastases in transit through veins or lymphatic vessels outside the resection margin at time of operation
Lymph nodes in the resection specimen may have metastases and the operation may still be curative
= macro-metastasis No metastases in lungs
= micro-metastasis = Arterial blood flow = Venous blood flow = Lymph flow
No metastases in other organs
In principle, all the tumor cells in the primary mass, macro-metastases and micro-metastases must be included in the resected specimen(s). The resection specimen includes primary tumor and the largest possible margin of normal tissue, including lymph nodes, which might contain micrometastases.
FIGURE 12.1
Circumstances in which surgery is curative of a tumor.
12.2 Classification of operations
=recurrent mass of metastatic tumor
Focal extension of tumor mass
•
• •
Other •
• •
•
•
Organs
••
•
•
•
1. After this operation, tumor can potentially recur from focal extension of tumor mass, from tumor cells in transit to lymph nodes, in lymph nodes, as well as in the blood vessels, in the lungs and in other organs.
•
•
• •
•
•
Other •
• •
•
Organs
•
•
•
• •
• ••
•
Other •
• •
•
Organs
•
12.2.5 Palliative procedures: “debulking,” removal of local recurrences, and removal of metastases (a) “Debulking”/“cytoreductive” operations This kind of operation is designed to reduce the amount of tumor in the body. It is usually used for intraabdominal tumors which are distending the abdomen. Most cases are of ovarian, colorectal, or gastric origin, with others being less common [18]. The aim is to extend life by prevention of lethal abdominal complications. The issue is complicated, but the usual rationales are [19]
•
2. After this operation, tumor can potentially only recur from tumor cells in transit in lymph or venules, in lymph nodes, in lungs or other organs
•
343
•
• 3. In this operation, tumor can potentially only recur from tumour cells in transit in lymph beyond local lymph nodes or in venules, in lungs or other organs Note: probably only a small and unpredictable proportion of micro-metastases will grow into clinically appreciable metastases, also at an unpredictable rate.
FIGURE 12.2
Sites of potential recurrence of malignant tumors depend on extent of surgical resection of primary tumor.
(vi) difficult dissections; (vii) rapid spread of carcinoma released from the incarceration of fibrosis; (viii) radio-osteonecrosis; (ix) induced tissue allergies; (x) narcotic addition from treatment for intolerable pain, and (xi) general inanition. All these are fundamentally the result of diminished blood supply, lowered vitality of the irradiated tissue, and excessive fibrosis [17]. They are most problematic when they occur in the abdomen.
(i) Removing large necrotic masses promotes drug delivery to smaller tumors with good blood supply (ii) Removing resistant clones decreases the likelihood of early onset drug resistance (iii) The smaller implants have a higher growth fraction that should be more chemosensitive (iv) Removing cancer in specific locations, such as tumors causing a bowel obstruction, improves the patient’s nutritional and immunologic status. Nevertheless, significantly benefit occurs only if the debulking removes all nodules >1 cm (Fig. 12.3). Second debulking operations may be considered for the same reasons as the primary surgery. However, the first operation often results in fibrosis, which can be difficult to distinguish from recurrent tumor. Recurrent ovarian cancer in particular tends to be more aggressive, with much more heterogeneous disease presentations (see Ref 19). (b) Removal of local recurrences The rationale for these operations is similar to those for debulking. The surgical problems are those of operating in scarring from the previous operation, and associated difficulty dissecting tumor from vital structures. For example, locally recurrent carcinoma of the
344
12. Principles of surgery for tumors
localized pain [22]. In up to 80% of cases, the targeted symptoms do not recur before deathdso that the operations can be considered to have improved the quality of the terminal phase of the patients’ lives [23]. (b) Reconstruction This term is often used in relation to plastic surgery, but in surgical oncology, it has the special meaning of reconstruction of anatomy necessarily affected by an excisional cancer operation. The main types are as follows [24]: FIGURE 12.3
Debulking or cytoreduction. Source: Fallis SA, Moran BJ. Management of pseudomyxoma peritonei. JBUON 2015; 20 (Suppl. 1): S48.
rectum may involve the vagina and uterus or prostate and bladder. In the past, contraindications to second surgical operations for recurrent rectal carcinoma included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3, and lateral pelvic wall involvement [20]. For loco-recurrent breast carcinoma, the greatest difficulty arises if the recurrence is in the chest wall, and the patient has had radiotherapy to the region. Loco-recurrent carcinomas of the lung and prostate are infrequently treated surgically.
12.2.6 Other (a) For relief of specific complications These are palliative in nature (see Section 19. 1) and may be helpful in the treatment of tumors in almost all organs of the body [21]. Examples are fixation of fractures associated with metastatic tumors in bone, removal of tissue to relieve obstruction of a hollow organ, diversion of a hollow organ, draining of fluid collections, such as malignant pleural effusion, and severing afferent nerves to relieve chronic
(i) Skin, tendon, and bone grafts. The surgeon transplants healthy skin, tendon, or bone to a new place in or on the body. The transplanted tissue does not have its own blood supply. This means that new blood vessels must grow. (ii) Local flap surgery. This approach uses nearby body tissue to cover the area affected by cancer surgery. The tissue is not disconnected from the body or blood supply but moved while still attached to the nearby area. See example Fig. 12.4. (iii) Artificial implants. Sometimes, an artificial implant replaces a damaged body part. Examples include breast, testicular, and penile implants. (iv) Scar revisions. These surgeries help minimize the appearance of scars from an earlier surgery. The organs most commonly requiring reconstruction are the breastdafter partial, simple, or more extensive resectiondthe face, and the oral cavity. (c) Prophylactic Organs may be removed before a cancer develops from patients with strong genetic or other predispositions to cancers of the particular organ. The commonest are breast and ovary. A recent systemic review found that
12.3 Aspects of particular cancer operations and their complications
345
FIGURE 12.4 Rhomboid flap surgery. A single rhomboid flap is very useful for defects that cannot be closed directly and abut an area of laxity. The orientation of the rhomboid is designed so that the flap donor site will close easily once the flap is transposed. Each rhomboid offers the possibility of four flap choices, each arising from the short axis of the rhomboid. Source: UpToDate Graphic 77521 Version 7.0. Bilateral risk-reducing mastectomy provides a 90% to 95% risk reduction in BRCA mutation carriers, although the data do not demonstrate improved mortality. The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival. [25].
As another example, the risk of colorectal cancer for any patient with ulcerative colitis is known to be elevated and is estimated to be 2% after 10 years, 8% after 20 years, and 18% after 30 years of disease. Total proctocolectomy was once commonly recommended to a patient TABLE 12.1
after 10 years or more of colitis. However, with regular surveillance colonoscopies, colectomy is less frequently necessary [26,27].
12.3 Aspects of particular cancer operations and their complications The details of the operation depend on the type of tumor [28]. This is because the types of spread of malignant tumors are variable according to type (Table 12.1).
Common cancers, surgical operations, and possible complications.
1. Lung carcinoma Lobectomy or pneumonectomy
Breakdown of bronchial closure causes pneumothorax
2. Colorectal carcinoma Partial colectomy
Breakdown of anastomosis
3. Breast carcinoma Lumpectomy, “simple” mastectomy
Usually none
Radical mastectomy
Lymphedema of the arm
4. Prostate carcinoma Transurethral resection (“TURP”)
Usually none significant
Radical prostatectomy
Urinary incontinence, impotence
These are in addition to the general complications of hemorrhage and infection.
346
12. Principles of surgery for tumors
12.3.1 Lung (a) Biopsies Because most carcinomas of the lung are central, most biopsies are taken through the bronchi using fiber-optic bronchoscopes. To assist the process, the end of the bronchoscope is fitted with an ultrasound device, which shows the operator the location of the lesion to be biopsied. The method can also be used to biopsy lymph nodes in the hilum of the lung. Aspiration biopsies are usual. Another avenue of lung biopsy is through the chest wall. This can be done with video guidance (VAT: video-assisted transthoracic biopsy). Pleural biopsies can be taken and subpleural tumors can be resected by this method. (b) Resections (i) Wedge resection
If the surgeon cannot remove an entire lobe of the lung, the surgeon can remove the tumor, surrounded by a margin of healthy lung. (ii) Segmentectomy
This is another way to remove the cancer when an entire lobe of the lung cannot be removed. In a segmentectomy, the surgeon removes the portion of the lung where the cancer developed.
cell carcinomas. For possible surgical approaches, they are divided into central (hilar and para-hilar) and peripheral sites. Resection of central lesions: the major problem of lung surgery is control of bleeding and prevention of air leaking from the bronchial tree. In early days, whole lung removal was carried out because it was easier to achieve these requisites. However, since the introduction of video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery, the smallest possible amount of normal lung tissue is taken along with the tumor. Lower morbidity has been associated with such procedures [30]. The drawback of this is that any intrapulmonary metastases of the tumor, the equivalent of micrometastases in other sites, is not removed, thus increasing the chances of local recurrence in the same lung [31]. During an open-thorax operation on the lung, the bronchial, hilar, and paratracheal lymph nodes are often resected. They may be sampled as part of operations which involve only resection of a part of a lobe. Small peripheral lesions may be removed via the chest wall (VATS, see above). All decisions concerning the particular operation for a patient rely on the imaging techniques described in Chapter 11 [32].
(iii) Lobectomy
This operation included bronchial lymph nodes and hence gives more tissue for staging (Fig. 12.5). (iv) Pneumonectomy
If the tumor is close to the center of the chest, the surgeon may have to remove the entire lung [29]. https://www.cancer.net/cancer-types/ lung-cancer-non-small-cell/treatment-options. For most treatment purposes, lung cancers are divided into small cell cancers, which are treated with nonsurgical methods and rarely resected, and nonsmall cell cancers, which are resected if the site, stage, and comorbidities permit. The remainder of this subsection refers to nonsmall
12.3.2 Colon and rectum (a) Biopsies Biopsies for diagnosis are taken at diagnostic colonoscopy. Occasionally, laparoscopy for another reason may reveal a carcinoma of the large bowel, and it may be biopsied from the serosa, or an affected lymph node may be taken. Aspiration biopsies are usually not indicated. (b) Resections Small polypoid cancers may be removed by polypectomy at colonoscopy. For larger lesions, a partial colectomy is required. Depending on
347
12.3 Aspects of particular cancer operations and their complications
(A) 1 lobe removed
(B)
(C)
Lung removed 2 lobes removed
FIGURE 12.5 Surgery for lung cancer. (A) Removal of single lobe. (B) Removal of two lower lobes. (C) Pneumonectomy Source: © Cancer Research UK (2002) All right reserved. Lung Cancer. Types of Surgery. https://www.cancerresearchuk.org/aboutcancer/lung-cancer/treatment/surgery/types?_ga=2.2887218.302713515.1569976807-1595875044.1551091594
the site of the cancer, the limits of the partial colectomy are dictated by the vascular supply of the region. Local lymph nodes (i.e., those adjacent to the arteries leading to the tumor) are almost always removed. This improves prognosis because it prevents local recurrence from tumor micrometastases or larger deposits in the nodes. However, removing additional nodes, for example, the para-aortic lymph nodes, does not seem to confer any particular benefit (Fig. 12.6). Resection of carcinomas of the rectum is complicated because of the following:
(i) there is no meso-structure. Instead, the rectum is close to the pelvic wall and nerves, as well as the genital organs and bladder. The clearance of the tumor at these margins is important for possible postsurgical radiation or chemotherapy (ii) the competence of the anal sphincter may be jeopardized (iii) lymph drainage from the lower two-thirds of the rectum is to the internal iliac nodes. Details of current recommended practices are given in the MD Anderson Cancer Center treatment algorithm [33].
348
12. Principles of surgery for tumors
Transverse colon
(A)
(B) Splenic flexure
Hepatic flexure
Descending colon
(F)
(C) Ascending colon
Sigmoid colon
Rectum
(E)
(D)
FIGURE 12.6 Anatomic resection commonly used for cancer at different sites within the large bowel. (A) Right hemicolectomy. (B) Extended right hemicolectomy. (C) Transverse colectomy. (D) Left hemicolectomy. (E) Sigmoid colectomy. (F) Abdominal perineal resection. Black circles signify the location of the cancer. Source: Kuethe, J. Malignant Colorectal and Perianal Disease. The Mont Reid Surgical Handbook. 2018. pp. 492e506.e1.
12.3.3 Breast (a) Biopsies Biopsies are one of the controversial issues in breast cancer. Initially all biopsies were “open.” In the 1970s, fine-needle aspiration biopsies were widely used. Ultimately, the rates of nondiagnostic results, false positives, and false negatives were considered too high, and needle core biopsies were introduced. (b) Resection The optimum operation for carcinoma of the female breast has a very long history of controversy. The earliest operations were lumpectomies, but from the 1890s, removal of the whole
breastdto excise multifocal lesions, as well as intrabreast micrometastasesdbecame popular. In that era, cases of carcinoma were usually large and often ulcerated the skin with the sometimesfatal complications of bleeding and infection. These operations were beneficial in preventing death from these local complications. Subsequently, in an attempt to remove all lymph node metastases, the standard operation for carcinoma of the breast included removal of whole breast, underlying muscle, and the axillary, and sometimes additional nodes all in continuity (Halstead’s operation) [34] (see Fig. 12.7). The reason for the failure of lymph node removal to cure all cases of carcinomas is that malignant tumors spread through the
12.3 Aspects of particular cancer operations and their complications
349
FIGURE 12.7 Radical mastectomy. Source: Bland KI, Klimberg VS, Copeland EM Halstead Radical Mastectomy. The Breast 5th ed. Elsevier, 2018 pp 422-442.e2. https://www.sciencedirect.com/science/article/pii/B9780323359559000301
blood vessels as well as the lymphatics, so that excision of the lymph nodes does not affect tumor cells which havedin the period of time before diagnosisdinvaded local blood vessels and been deposited in distant organs as micrometastases. In recent years, with increased awareness of carcinoma, and the mass screening by selfexamination, carcinomas of the breast have been discovered earlier, and hence are generally smaller than before the era of screening. Radical mastectomy has been almost completely abandoned because it is of no substantial additional benefit in terms of increased life of the patients over lumpectomy or simple mastectomy. Furthermore, radio- and chemotherapies have been added to the therapeutic options, either as primary therapy or in additiondbefore or afterdto surgery. Currently, there is no clear evidence that any regime is markedly superior to the other regimes. In this situation, the patients are being asked to involve themselves in decisions about which treatment is to be given. However, there are few decision aids which might support patients in this role [35]. The problem of decision-making is accentuated by the fact that if lumpectomy is followed
by recurrence, the recurrence can be removed. According to a trial cited by The MD Anderson Cancer Center, patients with recurrences after lumpectomy had similar survival times to those who had mastectomy at the outset. A further matter is that some untreated cases have a long survival. Boyages et al. [36] in 1999 reported a recurrence rate of 22.5%, 8.9%, and 1.4% following breast-conserving surgery alone, breast-conserving surgery with radiation therapy, and mastectomy, respectively. In patients who underwent breast-conserving surgery alone, approximately 50% of the recurrences were invasive cancers. Although recurrence rates are higher in patients who undergo breast-conserving surgery than in patients who undergo mastectomy, no survival advantage has been shown for patients treated with mastectomy.
12.3.4 Prostate (a) Biopsies Biopsies are all of needle type, using a transrectal approach. The lobes of the prostate are biopsied individually, often with imaging guidance to any suspicious foci.
350
12. Principles of surgery for tumors
(b) Resections (i) If the tumor is shown by imaging to be small and near the urethra in the prostate, transurethral resection may be an option. (ii) “Simple prostatectomy” (the prostate alone) is not recommended for proven cancers. In “radical prostatectomy,” the prostate is removed whole with seminal vesicles and both vasa deferentia by any of these approaches: (iii) Retropubic: via the lower abdominal wall and behind the pubic bone to remove the prostate anteriorly. (iv) Suprapubic: via the lower abdominal wall and through the bladder to remove the prostate upward. (v) Perineal: via the perineum, and between the rectum and scrotum removing the prostate posteriorly. It should be noted that (a) whether or not surgery is preferable to radiotherapy and (b) the optimum type of prostatectomy are both controversial issues.
Sarcomas as a group spread via the blood vessels, and rarely spread via the lymphatics. Hence, resecting lymph nodes in the region of a sarcoma is rarely carried out.
12.4 “Robotic” surgery 12.4.1 Background Most of the operative instruments and techniques developed in recent decades, for example, stents, minimally invasive surgery, and endoscopic microsurgery, have been accepted into practice. More recently, large numbers of imaging methods mentioned in Chapter 10 have been adapted to assist particular operations. The major new development since the early 1990s has been in the field of “robotic surgery,” in which the fine manipulations are delivered via computerized instruments, under the control of the surgeon. To 2016, 1.75 million procedures have been done in the United States [37]. The technique has been applied to cancers of virtually all the organs of the body (Fig. 12.8).
12.4.2 Advantages and disadvantages 12.3.5 Other Carcinomas of the stomach are usually removed with the lesser and greater omenta, together with any palpable resectable masses in lymph nodes. In addition, any mass found in the liver may be removed. For carcinomas of the kidney, usually the whole organ is removed with any macroscopically enlarged nodes. If no enlarged nodes are found, the para-aortic region of the body is not resected. Carcinomas of the testis are often treated by removal of testis with a separate operation to remove para-aortic lymph nodes. This is because the lymphatics of the testis drain to these nodes first.
The advantages are said to be greater precision for delicate operations, for example, in neurosurgery, and indeed, operations that are not possible manually. Another advantage may be reduced surgeon fatigue, and hence fewer “oops” events in the procedures. On the other hand, the operator has no tactile feedback to warn of unexpected pathology or anatomical arrangement, which may lead to more accidental negative events. Hemorrhage may be difficult to deal with if the computer program is not capable of immediate actions [38,39]. There is a delay phenomenon between the operator’s instructions and the robot’s actions. This means that the surgeon must use equipment with fixed, and preferably,
351
12.5 Translational notes on surgery in cases of cancer Roll Insertion
EndoWrist instruments with 7 degrees of freedom: insertion, external yaw, external pitch, internal yaw, internal pitch, roll and grip
Internal yaw Internal pitch
Grip
Patient-side robotic cart
External pitch
Vision tower
External yaw
Surgeonʹs control
Providing management of corresponding instruments with master manipulators
Surgical cart with single access port
FIGURE 12.8 Robotic surgery devices. Source: Liu HeH, Li L-J, Shi B et al. Robotic surgical systems in maxillofacial surgery: a review. Int J Oral Sci 9:63e73 (2017). https://www.nature.com/articles/ijos201724/figures/1
very short delay periods. Equipment failures are another source of difficulty. The main disadvantage, however, is mainly of cost, both in equipment, and in the training of the operators [40]. A 2017 study found that Randomized controlled trial evidence comparing robot-assisted radical prostatectomy over an open retropubic approach failed to show any difference between urogenital or early oncological outcomes at 6, 12, or 24 weeks. However, the study did demonstrate a shorter operating time, reduced length of stay and estimated total blood loss [41].
12.5 Translational notes on surgery in cases of cancer 1. Operations performed to palliate malignant tumors are an important part of surgical oncology. However, when considering a palliative operation, it is helpful to keep in mind that a symptom cannot be made better if the patient is asymptomatic. Many procedures have their own side effects and as patients who require palliative surgery are already weakened, the decision to undertake surgery is not straightforward.
352
12. Principles of surgery for tumors
2. Surgery to remove metastases is a relatively new facet of cancer surgery. The success, however, is real and is based on what is known as the “seeds and soil” hypothesisdthat cancer cells (seeds) must find the right soil (target organ) in which to germinate. The distribution might be random but the subsequent growth colonies can be targeted. 3. The value of lymph node removal where the nodes contain tumor has been controversial and is an ongoing discourse. 4. General points of treatment which survive do so on the basis of the accumulated evidence of their efficacy [42].
[10]
[11]
[12]
[13]
[14]
[15]
References [1] Ochsner JL. Minimally invasive surgical procedures. Ochsner J 2000;2(3):135e6. [2] National Cancer Institute. Dictionary of Cancer Terms. Minimally invasive surgery. https://www.cancer. gov/publications/dictionaries/cancer-terms/def/ minimally-invasive-surgery [Accessed April 2019]. [3] Mayo Clinic. Patient Care and Health Information. Minimally Invasive Surgery. https://www. mayoclinic.org/tests-procedures/minimally-invasivesurgery/about/pac-20384771 [Accessed April 2019]. [4] Thompson BM, Sparks RA, Seavey J, et al. Informed consent training improves surgery resident performance in simulated encounters with standardized patients. Am J Surg 2015;210(3):578e84. [5] US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Revisions to the Hospital Interpretive Guidelines for Informed Consent. https://www.cms.gov/Medicare/Provider-Enrollment -and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-17.pdf [Accessed April 2019]. [6] Kataria T, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40(3):371e82. [7] Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology 2013;119:1310e21. [8] UpToDate. Overview of sentinel lymph node biopsy in breast cancer. Topic 810 Version 38.0 https://www. uptodate.com/contents/overview-of-sentinel-lymphnode-biopsy-in-breast-cancer [Accessed April 2019]. [9] Kataria K, Srivastava A, Qaiser D. What is a false negative sentinel node biopsy: definition, reasons and ways to minimize it? Indian J Surg 2016;78(5):396e401. https://doi.org/10.1007/s12262-016-1531-9.
[16]
[17] [18]
[19]
[20]
[21] [22]
[23]
[24]
[25]
Bromham N, Schmidt-Hansen M, Astin M, et al. Axillary treatment for operable primary breast cancer. Cochrane Database Syst Rev 2017;1:CD004561. Zager JS, Gastman BR, Leachman S, et al. Performance of a prognostic 31-gene expression profile in an independent cohort of 523 cutaneous melanoma patients. BMC Canc 2018;18(1):130. Torgesen I. Sentinel node biopsy for melanoma: unnecessary treatment? BMJ 2013;346:18e20. BMJ 2013;346: e8645. Coldiron BM. Sentinel node biopsy: who needs it? MDEdge e Dermatology. 2018. https://www. mdedge.com/edermatologynews/article/156653/mela noma/sentinel-node-biopsy-who-needs-it. Torjesen I. Sentinel node biopsy for melanoma: unnecessary treatment? BMJ 2013;346:e8645. https://doiorg.salus.idm.oclc.org/10.1136/bmj.e8645. Kyrgidis A, Tzellos T, Mocellin S, et al. Sentinel lymph node biopsy followed by lymph node dissection for localised primary cutaneous melanoma. Cochrane Database Syst Rev 2015;16(5):CD010307. Mauri D, Pavlidis N, Ioannidis JP. Neoadjuvant versus adjuvant systemic treatment in breast cancer: a metaanalysis. J Natl Cancer Inst 2005;97:188e94. Robinson DW. The hazards of surgery in irradiated tissue. AMA Arch Surg 1955;71(3):410e8. Haouimi A, Gaillard F et al. Peritoneal metastases. Radiopaedia. https://radiopaedia.org/articles/ peritoneal-metastases [Accessed April 2019]. Schorg JO, McCann C, Del Carmen MG. Surgical debulking of ovarian cancer: what difference does it make? Rev Obstet Gynecol 2010;3:111e7. Lee DJ, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: How far have we come? World J Gastroenterol 2017;23:4170e80. Wichmann MW, Maddern G, editors. Palliative surgery. New York: Springer; 2014. Hanna J, Blazer DG, Mosca PJ. Overview of palliative surgery: principles and priorities. J Palliat Care Med 2:132. Krouse RS, Nelson RA, Farell BR, et al. Surgical palliation at a cancer center: incidence and outcomes. Ach Surg 2001;136:773e8. American Society for Clinical Oncology (ASCO). Cancer.Net. Reconstructive surgery. 2018. https://www. cancer.net/navigating-cancer-care/how-cancer-treated/ surgery/reconstructive-surgery. Ludwig KK, Neuner J, Butler A, et al. Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review. Am J Surg 2016;212(4):660e9.
References
[26] Provenzale D, Kowdley KV, Arora S, Wong JB. Prophylactic colectomy or surveillance for chronic ulcerative colitis? A decision analysis. Gastroenterology 1995;109:1188e96. [27] Lakatos PL, Lakatos L. Risk for colorectal cancer in ulcerative colitis: changes, causes and management strategies. World J Gastroenterol 2008;14:3937e47. [28] Silberman H, Silberman AW, editors. Principles and practice of surgical oncology. Philadelphia PA: LWW/Wolters Kluwer; 2010. [29] American Society for Clinical Oncology (ASCO). Cancer.Net. Lung cancer e Non-small cell. https://www. cancer.net/cancer-types/lung-cancer-non-small-cell/ treatment-options [Accessed April 2019]. [30] Agzarian J, Fahim C, Shargall Y. The use of roboticassisted thoracic surgery for lung resection: a comprehensive systematic review. Semin Thorac Cardiovasc Surg 2016;28(1):182. Epub 2016 Feb 9. [31] Midthun DE. Overview of the initial treatment and prognosis of lung cancer. UpToDate, Topic 4639 Version 49.0, last updated March 2019. [32] Leong S, Ju H, Marshall H, Bowman R, et al. Electromagnetic navigation bronchoscopy: a descriptive analysis. J Thorac Dis 2012;4:173e85. [33] MD Anderson Cancer Center. Colon Cancer treatment algorithm. 2018. https://www.mdanderson.org/ content/dam/mdanderson/documents/forphysicians/algorithms/cancer-treatment/catreatment-colon-web-algorithm.pdf. [34] Sakorafas Gh, Safioleas M. Breast cancer surgery: an historical narrative. Part II. 18th and 19th centuries.
[35]
[36]
[37]
[38]
[39]
[40]
[41] [42]
353 Eur J Cancer Care 2010;19(1):6e29. https://doi.org/ 10.1111/j.1365-2354.2008.01060.x. Zdenkowski N, Butow P, Tesson S, Boyle F. A systematic review of decision aids for patients making a decision about treatment for early breast cancer. Breast 2016;26:31e45. Boyages J, Delaney G, Taylor R. Predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis. Cancer 1999;85(3):616e28. Alemzadeh H, Raman J, Leveson N, et al. Adverse events in robotic surgery: a retrospective study of 14 years of FDA data. PLoS One 2016;11(4):e0151470. Franklin A, Campbell J, Pokala N. Hemorrhagic complications of robot-assisted laparoscopic partial nephrectomy for renal masses. J Clin Oncol 2016; 34(2_Suppl. l). 621-621. The Joint Commission, Division of Healthcare Improvement. Potential risks of robotic surgery. QuickSafety 2014;(3). https://www.jointcommission.org/ assets/1/23/Quick_Safety_Issue_Three_June_2014. pdf. Lepton K. Robotic surgery e advantages and disadvantages. Future Technology 500. February 2011. http://www.futuretechnology500.com/index.php/ future-medical-technology/robotic-surgeryadvantages-and-disadvantages. Warren H, Dasgupta P. The future of robotics. Investig Clin Urol 2017;58(5):297e8. Whalen G. Principles of surgical oncology. In: Cancer concepts: a guidebook for the non-oncologist. Worcester, MA: University of Massachusetts Medical School; 2016. https://doi.org/10.7191/cancer_concepts.1022.
12 Principles of surgery for tumors O U T L I N E 12.1 Preoperative considerations 340 12.1.1 Review of clinical features, imaging, and comorbidities 340 12.1.2 Informed consent 340 12.1.3 Facilities 340 12.2 Classification of operations 340 12.2.1 Biopsies for diagnosis 340 12.2.2 Biopsies for staging: sentinel node biopsy 341 (a) General 341 (b) Sentinel node biopsies in the treatment of carcinoma of the breast 341 (c) Sentinel node biopsies in the treatment of malignant melanoma 341 12.2.3 Removal of the primary tumor 342 12.2.4 After neoadjuvant chemotherapy and radiotherapy 342 12.2.5 Palliative procedures: “debulking,” removal of local recurrences, and removal of metastases 343 (a) “Debulking”/“cytoreductive” operations 343 (b) Removal of local recurrences 343 12.2.6 Other 344
Principles of Tumors https://doi.org/10.1016/B978-0-12-816920-9.00012-2
(a) For relief of specific complications (b) Reconstruction (c) Prophylactic
344 344 344
12.3 Aspects of particular cancer operations and their complications 345 12.3.1 Lung 346 (a) Biopsies 346 (b) Resections 346 12.3.2 Colon and rectum 346 (a) Biopsies 346 (b) Resections 346 12.3.3 Breast 348 (a) Biopsies 348 (b) Resection 348 12.3.4 Prostate 349 (a) Biopsies 349 (b) Resections 350 12.3.5 Other 350 12.4 “Robotic” surgery 12.4.1 Background 12.4.2 Advantages and disadvantages
350 350 350
12.5 Translational notes on surgery in cases of cancer 351 References
339
352
Copyright © 2020 Elsevier Inc. All rights reserved.
340
12. Principles of surgery for tumors
Surgery is the mainstay of treatment of primary solid tumors and, to a lesser extent, secondary tumors. Extensive removal of organs became possible in the late 19th century, with technical advances in anesthesia and antisepsis, and later in the support services, especially blood transfusion. This chapter gives an overview of current surgical therapies for tumors.
components are described in US government guidelines [5] and can be summarized: (i) Reasons/benefits of the proposed surgery, (ii) Description of and risks of the proposed surgery and anesthesia to be used, (iii) Pros and cons of no treatment and treatment alternatives, (iv) Qualifications, experience, and credentials for their roles in the operation, of all persons involved in the surgery and postoperative care.
12.1 Preoperative considerations 12.1.1 Review of clinical features, imaging, and comorbidities When referred a patient who has a tumor which may be treatable by surgery, the surgeon assesses all aspects of the case: Is the diagnosis correct? What is the stage of the tumor? Can the tumor be resected? Will the benefits of the operation outweigh the complications of the surgery? The anesthetist and the surgeon together consider the additional questions: is the patient physically fit for the operation? Are there any contravening comorbidities or drug therapies? For this, all the clinical features of the case, as well as all the diagnostic imaging and other tests, are reviewed and supplemented when necessary. The next step is to select the optimum technique to achieve the objective of the surgery with minimum disturbance to normal tissues. This concept is usually referred to as using “minimally invasive” techniques [1,2]. In general, minimally invasive surgery is associated with less pain, a shorter hospital stay, and fewer complications [3].
12.1.2 Informed consent Informed consent is an important aspect of surgery because outcomes may not measure up to patients’ expectations [4]. The essential
12.1.3 Facilities With current pressures on medical resources, the surgeon and anesthetist also have to decide on which conditions are safe for the operation to be carried out. The options may include (i) full-support operating theaters, (ii) ambulatory conditions, usually involving short-duration general an anesthetic or sedation, and (iii) outpatient conditions when a local anesthetic is sufficient. The selection of facility is determined by the kind of operation contemplated [6,7].
12.2 Classification of operations Surgical procedures can be required at all phases in the treatment of a tumor.
12.2.1 Biopsies for diagnosis These include aspiration and core needle biopsies. When an incisional or excisional procedure follows the needle biopsy, the needle track of the previous biopsy should be removed in continuity. If any follow-up treatment especially radiotherapy is envisaged, anatomical markers, for example, radio-opaque clips, should be placed in the biopsy bed.
12.2 Classification of operations
12.2.2 Biopsies for staging: sentinel node biopsy (a) General According to the various staging protocols (see in Chapter 10), the detection of any remote deposit of tumor automatically classifies the case as M1 or higher in the TNM system (see in Section 10.4). Thus, if in the work-up of a case of apparent local tumor only, imaging demonstrates a suspicious lesion remote from the primary, a biopsy may be undertaken to determine its nature. If tumor is demonstrated, the stage is changed to “4” and the patient’s treatment may be significantly altered. This issue can arise in relation to any tumor type which is capable of metastasis. (b) Sentinel node biopsies in the treatment of carcinoma of the breast Staging biopsies to assist choice of operation is particularly relevant to carcinoma of the breast. In this disease, spread to axillary lymph nodes (N1-x in the TNM system) is common, and of great prognostic importance. Currently, imaging by ultrasound is usually routine, and any abnormal node is either biopsied by needle aspiration or removed. If, however, there is no abnormal node by ultrasound, it is important to determine if any small deposits are present in the axillary nodes. Complete axillary lymph node removal has significant side effects, especially chronic lymphedema of the arm. However, selective sampling of the node most likely to be the site of a small metastasis can be done. The procedure known as “sentinel node biopsy” is based on the assumption that if that first node (the “sentinel node”) has no tumor in it, then the other axillary nodes are unlikely to have tumor in them. The technical steps in identifying the “sentinel nodes” in a patient involve injecting the breast with a dye, which passes via lymphatic vessels to stain the lymph nodes in the axilla. The lowest node containing dye at exploration of the axilla is the sentinel node.
341
Current recommendations are that sentinel node biopsy should be performed on all early breast cancers, whether or not the nodes are abnormal by imaging. This includes patients with DCIS only on breast biopsy [8]. The primary assumptiondthat tumor cells pass to the anatomically lowest node in the axilla firstd might be questioned because the small lymphatic vessels in the breast and axilladas in most parts of the bodydare plexuses, and transiting cells have the opportunity to bypass any particular, or in fact, possibly all, local lymph nodes. This is supported by the findings that 1%e5% of patients who have had a sentinel node biopsy with no tumor found suffer subsequent tumor growths in their axillae [9]. The long-term outcome for patients who are sentinel node negative without axillary clearance but who developed local recurrence is not less than those who had axillary clearance. This is presumably because tumor cells spread via nonaxillary lymphaticsde.g., in the chest walldas well as through blood capillaries to the remainder of the body. The whole topic was considered in a recent Cochrane Review [10] concluding This review confirms the benefit of SLNB and axillary sampling as alternatives to ALND for axillary staging, supporting the view that ALND of the clinically and radiologically uninvolved axilla is no longer acceptable practice in people with breast cancer.
(c) Sentinel node biopsies in the treatment of malignant melanoma The principle described above for breast cancer has been applied to malignant melanoma. Melanomas, however, are probably more likely than carcinomas to spread via the blood stream, and so the rationale for this application may be weakened. Sentinel node biopsy can be done only for melanomas of the arms, legs, or head and neck. It is controversial because of the complications (especially permanent lymphedema) and the availability of nonsurgical prognostic markersdgenetic profiles [11e14].
342
12. Principles of surgery for tumors
A Cochrane review in 2015 concluded Currently this evidence is not sufficient to document a benefit of SLNB when compared to observation in individuals with primary localised cutaneous melanoma [15].
12.2.3 Removal of the primary tumor After diagnosis and staging of a particular tumor, surgical resection is usually undertaken if there is a reasonable zone of normal tissue at the edge of the tumor. If there is any uncertainty, a frozen section of the margin can be carried out. Margins should be as wide as possible. Recommendations are arbitrary. In all the following operations, if intraarterial chemotherapy is to be used, catheters can be inserted during the operation.
Notes on particular primary operative removals are given below (Figs. 12.1 and 12.2).
12.2.4 After neoadjuvant chemotherapy and radiotherapy Generally, prior treatment with chemotherapy (“neoadjuvant chemotherapy”) makes operative removal easier [16]. In contrast, preoperative radiotherapy causes devascularization and fibrosis of tissues, so that the ability to heal the wound is reduced. Some of the complications that make surgery in irradiated tissue more difficult or hazardous are the following: (i) Infection; (ii) poor wound healing; (iii) slough; (iv) exposure of tendons, bone, or other important structures; (v) difficult hemostasis and or secondary hemorrhage;
No micro-metastases in transit through veins or lymphatic vessels outside the resection margin at time of operation
Lymph nodes in the resection specimen may have metastases and the operation may still be curative
= macro-metastasis No metastases in lungs
= micro-metastasis = Arterial blood flow = Venous blood flow = Lymph flow
No metastases in other organs
In principle, all the tumor cells in the primary mass, macro-metastases and micro-metastases must be included in the resected specimen(s). The resection specimen includes primary tumor and the largest possible margin of normal tissue, including lymph nodes, which might contain micrometastases.
FIGURE 12.1
Circumstances in which surgery is curative of a tumor.
12.2 Classification of operations
=recurrent mass of metastatic tumor
Focal extension of tumor mass
•
• •
Other •
• •
•
•
Organs
••
•
•
•
1. After this operation, tumor can potentially recur from focal extension of tumor mass, from tumor cells in transit to lymph nodes, in lymph nodes, as well as in the blood vessels, in the lungs and in other organs.
•
•
• •
•
•
Other •
• •
•
Organs
•
•
•
• •
• ••
•
Other •
• •
•
Organs
•
12.2.5 Palliative procedures: “debulking,” removal of local recurrences, and removal of metastases (a) “Debulking”/“cytoreductive” operations This kind of operation is designed to reduce the amount of tumor in the body. It is usually used for intraabdominal tumors which are distending the abdomen. Most cases are of ovarian, colorectal, or gastric origin, with others being less common [18]. The aim is to extend life by prevention of lethal abdominal complications. The issue is complicated, but the usual rationales are [19]
•
2. After this operation, tumor can potentially only recur from tumor cells in transit in lymph or venules, in lymph nodes, in lungs or other organs
•
343
•
• 3. In this operation, tumor can potentially only recur from tumour cells in transit in lymph beyond local lymph nodes or in venules, in lungs or other organs Note: probably only a small and unpredictable proportion of micro-metastases will grow into clinically appreciable metastases, also at an unpredictable rate.
FIGURE 12.2
Sites of potential recurrence of malignant tumors depend on extent of surgical resection of primary tumor.
(vi) difficult dissections; (vii) rapid spread of carcinoma released from the incarceration of fibrosis; (viii) radio-osteonecrosis; (ix) induced tissue allergies; (x) narcotic addition from treatment for intolerable pain, and (xi) general inanition. All these are fundamentally the result of diminished blood supply, lowered vitality of the irradiated tissue, and excessive fibrosis [17]. They are most problematic when they occur in the abdomen.
(i) Removing large necrotic masses promotes drug delivery to smaller tumors with good blood supply (ii) Removing resistant clones decreases the likelihood of early onset drug resistance (iii) The smaller implants have a higher growth fraction that should be more chemosensitive (iv) Removing cancer in specific locations, such as tumors causing a bowel obstruction, improves the patient’s nutritional and immunologic status. Nevertheless, significantly benefit occurs only if the debulking removes all nodules >1 cm (Fig. 12.3). Second debulking operations may be considered for the same reasons as the primary surgery. However, the first operation often results in fibrosis, which can be difficult to distinguish from recurrent tumor. Recurrent ovarian cancer in particular tends to be more aggressive, with much more heterogeneous disease presentations (see Ref 19). (b) Removal of local recurrences The rationale for these operations is similar to those for debulking. The surgical problems are those of operating in scarring from the previous operation, and associated difficulty dissecting tumor from vital structures. For example, locally recurrent carcinoma of the
344
12. Principles of surgery for tumors
localized pain [22]. In up to 80% of cases, the targeted symptoms do not recur before deathdso that the operations can be considered to have improved the quality of the terminal phase of the patients’ lives [23]. (b) Reconstruction This term is often used in relation to plastic surgery, but in surgical oncology, it has the special meaning of reconstruction of anatomy necessarily affected by an excisional cancer operation. The main types are as follows [24]: FIGURE 12.3
Debulking or cytoreduction. Source: Fallis SA, Moran BJ. Management of pseudomyxoma peritonei. JBUON 2015; 20 (Suppl. 1): S48.
rectum may involve the vagina and uterus or prostate and bladder. In the past, contraindications to second surgical operations for recurrent rectal carcinoma included anterior involvement of the pubic bone, sacral invasions above the level of S2/S3, and lateral pelvic wall involvement [20]. For loco-recurrent breast carcinoma, the greatest difficulty arises if the recurrence is in the chest wall, and the patient has had radiotherapy to the region. Loco-recurrent carcinomas of the lung and prostate are infrequently treated surgically.
12.2.6 Other (a) For relief of specific complications These are palliative in nature (see Section 19. 1) and may be helpful in the treatment of tumors in almost all organs of the body [21]. Examples are fixation of fractures associated with metastatic tumors in bone, removal of tissue to relieve obstruction of a hollow organ, diversion of a hollow organ, draining of fluid collections, such as malignant pleural effusion, and severing afferent nerves to relieve chronic
(i) Skin, tendon, and bone grafts. The surgeon transplants healthy skin, tendon, or bone to a new place in or on the body. The transplanted tissue does not have its own blood supply. This means that new blood vessels must grow. (ii) Local flap surgery. This approach uses nearby body tissue to cover the area affected by cancer surgery. The tissue is not disconnected from the body or blood supply but moved while still attached to the nearby area. See example Fig. 12.4. (iii) Artificial implants. Sometimes, an artificial implant replaces a damaged body part. Examples include breast, testicular, and penile implants. (iv) Scar revisions. These surgeries help minimize the appearance of scars from an earlier surgery. The organs most commonly requiring reconstruction are the breastdafter partial, simple, or more extensive resectiondthe face, and the oral cavity. (c) Prophylactic Organs may be removed before a cancer develops from patients with strong genetic or other predispositions to cancers of the particular organ. The commonest are breast and ovary. A recent systemic review found that
12.3 Aspects of particular cancer operations and their complications
345
FIGURE 12.4 Rhomboid flap surgery. A single rhomboid flap is very useful for defects that cannot be closed directly and abut an area of laxity. The orientation of the rhomboid is designed so that the flap donor site will close easily once the flap is transposed. Each rhomboid offers the possibility of four flap choices, each arising from the short axis of the rhomboid. Source: UpToDate Graphic 77521 Version 7.0. Bilateral risk-reducing mastectomy provides a 90% to 95% risk reduction in BRCA mutation carriers, although the data do not demonstrate improved mortality. The reduction in ovarian and breast cancer risks using risk-reducing bilateral salpingo-oophorectomy has translated to improvement in survival. [25].
As another example, the risk of colorectal cancer for any patient with ulcerative colitis is known to be elevated and is estimated to be 2% after 10 years, 8% after 20 years, and 18% after 30 years of disease. Total proctocolectomy was once commonly recommended to a patient TABLE 12.1
after 10 years or more of colitis. However, with regular surveillance colonoscopies, colectomy is less frequently necessary [26,27].
12.3 Aspects of particular cancer operations and their complications The details of the operation depend on the type of tumor [28]. This is because the types of spread of malignant tumors are variable according to type (Table 12.1).
Common cancers, surgical operations, and possible complications.
1. Lung carcinoma Lobectomy or pneumonectomy
Breakdown of bronchial closure causes pneumothorax
2. Colorectal carcinoma Partial colectomy
Breakdown of anastomosis
3. Breast carcinoma Lumpectomy, “simple” mastectomy
Usually none
Radical mastectomy
Lymphedema of the arm
4. Prostate carcinoma Transurethral resection (“TURP”)
Usually none significant
Radical prostatectomy
Urinary incontinence, impotence
These are in addition to the general complications of hemorrhage and infection.
346
12. Principles of surgery for tumors
12.3.1 Lung (a) Biopsies Because most carcinomas of the lung are central, most biopsies are taken through the bronchi using fiber-optic bronchoscopes. To assist the process, the end of the bronchoscope is fitted with an ultrasound device, which shows the operator the location of the lesion to be biopsied. The method can also be used to biopsy lymph nodes in the hilum of the lung. Aspiration biopsies are usual. Another avenue of lung biopsy is through the chest wall. This can be done with video guidance (VAT: video-assisted transthoracic biopsy). Pleural biopsies can be taken and subpleural tumors can be resected by this method. (b) Resections (i) Wedge resection
If the surgeon cannot remove an entire lobe of the lung, the surgeon can remove the tumor, surrounded by a margin of healthy lung. (ii) Segmentectomy
This is another way to remove the cancer when an entire lobe of the lung cannot be removed. In a segmentectomy, the surgeon removes the portion of the lung where the cancer developed.
cell carcinomas. For possible surgical approaches, they are divided into central (hilar and para-hilar) and peripheral sites. Resection of central lesions: the major problem of lung surgery is control of bleeding and prevention of air leaking from the bronchial tree. In early days, whole lung removal was carried out because it was easier to achieve these requisites. However, since the introduction of video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery, the smallest possible amount of normal lung tissue is taken along with the tumor. Lower morbidity has been associated with such procedures [30]. The drawback of this is that any intrapulmonary metastases of the tumor, the equivalent of micrometastases in other sites, is not removed, thus increasing the chances of local recurrence in the same lung [31]. During an open-thorax operation on the lung, the bronchial, hilar, and paratracheal lymph nodes are often resected. They may be sampled as part of operations which involve only resection of a part of a lobe. Small peripheral lesions may be removed via the chest wall (VATS, see above). All decisions concerning the particular operation for a patient rely on the imaging techniques described in Chapter 11 [32].
(iii) Lobectomy
This operation included bronchial lymph nodes and hence gives more tissue for staging (Fig. 12.5). (iv) Pneumonectomy
If the tumor is close to the center of the chest, the surgeon may have to remove the entire lung [29]. https://www.cancer.net/cancer-types/ lung-cancer-non-small-cell/treatment-options. For most treatment purposes, lung cancers are divided into small cell cancers, which are treated with nonsurgical methods and rarely resected, and nonsmall cell cancers, which are resected if the site, stage, and comorbidities permit. The remainder of this subsection refers to nonsmall
12.3.2 Colon and rectum (a) Biopsies Biopsies for diagnosis are taken at diagnostic colonoscopy. Occasionally, laparoscopy for another reason may reveal a carcinoma of the large bowel, and it may be biopsied from the serosa, or an affected lymph node may be taken. Aspiration biopsies are usually not indicated. (b) Resections Small polypoid cancers may be removed by polypectomy at colonoscopy. For larger lesions, a partial colectomy is required. Depending on
347
12.3 Aspects of particular cancer operations and their complications
(A) 1 lobe removed
(B)
(C)
Lung removed 2 lobes removed
FIGURE 12.5 Surgery for lung cancer. (A) Removal of single lobe. (B) Removal of two lower lobes. (C) Pneumonectomy Source: © Cancer Research UK (2002) All right reserved. Lung Cancer. Types of Surgery. https://www.cancerresearchuk.org/aboutcancer/lung-cancer/treatment/surgery/types?_ga=2.2887218.302713515.1569976807-1595875044.1551091594
the site of the cancer, the limits of the partial colectomy are dictated by the vascular supply of the region. Local lymph nodes (i.e., those adjacent to the arteries leading to the tumor) are almost always removed. This improves prognosis because it prevents local recurrence from tumor micrometastases or larger deposits in the nodes. However, removing additional nodes, for example, the para-aortic lymph nodes, does not seem to confer any particular benefit (Fig. 12.6). Resection of carcinomas of the rectum is complicated because of the following:
(i) there is no meso-structure. Instead, the rectum is close to the pelvic wall and nerves, as well as the genital organs and bladder. The clearance of the tumor at these margins is important for possible postsurgical radiation or chemotherapy (ii) the competence of the anal sphincter may be jeopardized (iii) lymph drainage from the lower two-thirds of the rectum is to the internal iliac nodes. Details of current recommended practices are given in the MD Anderson Cancer Center treatment algorithm [33].
348
12. Principles of surgery for tumors
Transverse colon
(A)
(B) Splenic flexure
Hepatic flexure
Descending colon
(F)
(C) Ascending colon
Sigmoid colon
Rectum
(E)
(D)
FIGURE 12.6 Anatomic resection commonly used for cancer at different sites within the large bowel. (A) Right hemicolectomy. (B) Extended right hemicolectomy. (C) Transverse colectomy. (D) Left hemicolectomy. (E) Sigmoid colectomy. (F) Abdominal perineal resection. Black circles signify the location of the cancer. Source: Kuethe, J. Malignant Colorectal and Perianal Disease. The Mont Reid Surgical Handbook. 2018. pp. 492e506.e1.
12.3.3 Breast (a) Biopsies Biopsies are one of the controversial issues in breast cancer. Initially all biopsies were “open.” In the 1970s, fine-needle aspiration biopsies were widely used. Ultimately, the rates of nondiagnostic results, false positives, and false negatives were considered too high, and needle core biopsies were introduced. (b) Resection The optimum operation for carcinoma of the female breast has a very long history of controversy. The earliest operations were lumpectomies, but from the 1890s, removal of the whole
breastdto excise multifocal lesions, as well as intrabreast micrometastasesdbecame popular. In that era, cases of carcinoma were usually large and often ulcerated the skin with the sometimesfatal complications of bleeding and infection. These operations were beneficial in preventing death from these local complications. Subsequently, in an attempt to remove all lymph node metastases, the standard operation for carcinoma of the breast included removal of whole breast, underlying muscle, and the axillary, and sometimes additional nodes all in continuity (Halstead’s operation) [34] (see Fig. 12.7). The reason for the failure of lymph node removal to cure all cases of carcinomas is that malignant tumors spread through the
12.3 Aspects of particular cancer operations and their complications
349
FIGURE 12.7 Radical mastectomy. Source: Bland KI, Klimberg VS, Copeland EM Halstead Radical Mastectomy. The Breast 5th ed. Elsevier, 2018 pp 422-442.e2. https://www.sciencedirect.com/science/article/pii/B9780323359559000301
blood vessels as well as the lymphatics, so that excision of the lymph nodes does not affect tumor cells which havedin the period of time before diagnosisdinvaded local blood vessels and been deposited in distant organs as micrometastases. In recent years, with increased awareness of carcinoma, and the mass screening by selfexamination, carcinomas of the breast have been discovered earlier, and hence are generally smaller than before the era of screening. Radical mastectomy has been almost completely abandoned because it is of no substantial additional benefit in terms of increased life of the patients over lumpectomy or simple mastectomy. Furthermore, radio- and chemotherapies have been added to the therapeutic options, either as primary therapy or in additiondbefore or afterdto surgery. Currently, there is no clear evidence that any regime is markedly superior to the other regimes. In this situation, the patients are being asked to involve themselves in decisions about which treatment is to be given. However, there are few decision aids which might support patients in this role [35]. The problem of decision-making is accentuated by the fact that if lumpectomy is followed
by recurrence, the recurrence can be removed. According to a trial cited by The MD Anderson Cancer Center, patients with recurrences after lumpectomy had similar survival times to those who had mastectomy at the outset. A further matter is that some untreated cases have a long survival. Boyages et al. [36] in 1999 reported a recurrence rate of 22.5%, 8.9%, and 1.4% following breast-conserving surgery alone, breast-conserving surgery with radiation therapy, and mastectomy, respectively. In patients who underwent breast-conserving surgery alone, approximately 50% of the recurrences were invasive cancers. Although recurrence rates are higher in patients who undergo breast-conserving surgery than in patients who undergo mastectomy, no survival advantage has been shown for patients treated with mastectomy.
12.3.4 Prostate (a) Biopsies Biopsies are all of needle type, using a transrectal approach. The lobes of the prostate are biopsied individually, often with imaging guidance to any suspicious foci.
350
12. Principles of surgery for tumors
(b) Resections (i) If the tumor is shown by imaging to be small and near the urethra in the prostate, transurethral resection may be an option. (ii) “Simple prostatectomy” (the prostate alone) is not recommended for proven cancers. In “radical prostatectomy,” the prostate is removed whole with seminal vesicles and both vasa deferentia by any of these approaches: (iii) Retropubic: via the lower abdominal wall and behind the pubic bone to remove the prostate anteriorly. (iv) Suprapubic: via the lower abdominal wall and through the bladder to remove the prostate upward. (v) Perineal: via the perineum, and between the rectum and scrotum removing the prostate posteriorly. It should be noted that (a) whether or not surgery is preferable to radiotherapy and (b) the optimum type of prostatectomy are both controversial issues.
Sarcomas as a group spread via the blood vessels, and rarely spread via the lymphatics. Hence, resecting lymph nodes in the region of a sarcoma is rarely carried out.
12.4 “Robotic” surgery 12.4.1 Background Most of the operative instruments and techniques developed in recent decades, for example, stents, minimally invasive surgery, and endoscopic microsurgery, have been accepted into practice. More recently, large numbers of imaging methods mentioned in Chapter 10 have been adapted to assist particular operations. The major new development since the early 1990s has been in the field of “robotic surgery,” in which the fine manipulations are delivered via computerized instruments, under the control of the surgeon. To 2016, 1.75 million procedures have been done in the United States [37]. The technique has been applied to cancers of virtually all the organs of the body (Fig. 12.8).
12.4.2 Advantages and disadvantages 12.3.5 Other Carcinomas of the stomach are usually removed with the lesser and greater omenta, together with any palpable resectable masses in lymph nodes. In addition, any mass found in the liver may be removed. For carcinomas of the kidney, usually the whole organ is removed with any macroscopically enlarged nodes. If no enlarged nodes are found, the para-aortic region of the body is not resected. Carcinomas of the testis are often treated by removal of testis with a separate operation to remove para-aortic lymph nodes. This is because the lymphatics of the testis drain to these nodes first.
The advantages are said to be greater precision for delicate operations, for example, in neurosurgery, and indeed, operations that are not possible manually. Another advantage may be reduced surgeon fatigue, and hence fewer “oops” events in the procedures. On the other hand, the operator has no tactile feedback to warn of unexpected pathology or anatomical arrangement, which may lead to more accidental negative events. Hemorrhage may be difficult to deal with if the computer program is not capable of immediate actions [38,39]. There is a delay phenomenon between the operator’s instructions and the robot’s actions. This means that the surgeon must use equipment with fixed, and preferably,
351
12.5 Translational notes on surgery in cases of cancer Roll Insertion
EndoWrist instruments with 7 degrees of freedom: insertion, external yaw, external pitch, internal yaw, internal pitch, roll and grip
Internal yaw Internal pitch
Grip
Patient-side robotic cart
External pitch
Vision tower
External yaw
Surgeonʹs control
Providing management of corresponding instruments with master manipulators
Surgical cart with single access port
FIGURE 12.8 Robotic surgery devices. Source: Liu HeH, Li L-J, Shi B et al. Robotic surgical systems in maxillofacial surgery: a review. Int J Oral Sci 9:63e73 (2017). https://www.nature.com/articles/ijos201724/figures/1
very short delay periods. Equipment failures are another source of difficulty. The main disadvantage, however, is mainly of cost, both in equipment, and in the training of the operators [40]. A 2017 study found that Randomized controlled trial evidence comparing robot-assisted radical prostatectomy over an open retropubic approach failed to show any difference between urogenital or early oncological outcomes at 6, 12, or 24 weeks. However, the study did demonstrate a shorter operating time, reduced length of stay and estimated total blood loss [41].
12.5 Translational notes on surgery in cases of cancer 1. Operations performed to palliate malignant tumors are an important part of surgical oncology. However, when considering a palliative operation, it is helpful to keep in mind that a symptom cannot be made better if the patient is asymptomatic. Many procedures have their own side effects and as patients who require palliative surgery are already weakened, the decision to undertake surgery is not straightforward.
352
12. Principles of surgery for tumors
2. Surgery to remove metastases is a relatively new facet of cancer surgery. The success, however, is real and is based on what is known as the “seeds and soil” hypothesisdthat cancer cells (seeds) must find the right soil (target organ) in which to germinate. The distribution might be random but the subsequent growth colonies can be targeted. 3. The value of lymph node removal where the nodes contain tumor has been controversial and is an ongoing discourse. 4. General points of treatment which survive do so on the basis of the accumulated evidence of their efficacy [42].
[10]
[11]
[12]
[13]
[14]
[15]
References [1] Ochsner JL. Minimally invasive surgical procedures. Ochsner J 2000;2(3):135e6. [2] National Cancer Institute. Dictionary of Cancer Terms. Minimally invasive surgery. https://www.cancer. gov/publications/dictionaries/cancer-terms/def/ minimally-invasive-surgery [Accessed April 2019]. [3] Mayo Clinic. Patient Care and Health Information. Minimally Invasive Surgery. https://www. mayoclinic.org/tests-procedures/minimally-invasivesurgery/about/pac-20384771 [Accessed April 2019]. [4] Thompson BM, Sparks RA, Seavey J, et al. Informed consent training improves surgery resident performance in simulated encounters with standardized patients. Am J Surg 2015;210(3):578e84. [5] US Department of Health and Human Services. Centers for Medicare and Medicaid Services. Revisions to the Hospital Interpretive Guidelines for Informed Consent. https://www.cms.gov/Medicare/Provider-Enrollment -and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-17.pdf [Accessed April 2019]. [6] Kataria T, Cutter TW, Apfelbaum JL. Patient selection in outpatient surgery. Clin Plast Surg 2013;40(3):371e82. [7] Mathis MR, Naughton NN, Shanks AM, et al. Patient selection for day case-eligible surgery: identifying those at high risk for major complications. Anesthesiology 2013;119:1310e21. [8] UpToDate. Overview of sentinel lymph node biopsy in breast cancer. Topic 810 Version 38.0 https://www. uptodate.com/contents/overview-of-sentinel-lymphnode-biopsy-in-breast-cancer [Accessed April 2019]. [9] Kataria K, Srivastava A, Qaiser D. What is a false negative sentinel node biopsy: definition, reasons and ways to minimize it? Indian J Surg 2016;78(5):396e401. https://doi.org/10.1007/s12262-016-1531-9.
[16]
[17] [18]
[19]
[20]
[21] [22]
[23]
[24]
[25]
Bromham N, Schmidt-Hansen M, Astin M, et al. Axillary treatment for operable primary breast cancer. Cochrane Database Syst Rev 2017;1:CD004561. Zager JS, Gastman BR, Leachman S, et al. Performance of a prognostic 31-gene expression profile in an independent cohort of 523 cutaneous melanoma patients. BMC Canc 2018;18(1):130. Torgesen I. Sentinel node biopsy for melanoma: unnecessary treatment? BMJ 2013;346:18e20. BMJ 2013;346: e8645. Coldiron BM. Sentinel node biopsy: who needs it? MDEdge e Dermatology. 2018. https://www. mdedge.com/edermatologynews/article/156653/mela noma/sentinel-node-biopsy-who-needs-it. Torjesen I. Sentinel node biopsy for melanoma: unnecessary treatment? BMJ 2013;346:e8645. https://doiorg.salus.idm.oclc.org/10.1136/bmj.e8645. Kyrgidis A, Tzellos T, Mocellin S, et al. Sentinel lymph node biopsy followed by lymph node dissection for localised primary cutaneous melanoma. Cochrane Database Syst Rev 2015;16(5):CD010307. Mauri D, Pavlidis N, Ioannidis JP. Neoadjuvant versus adjuvant systemic treatment in breast cancer: a metaanalysis. J Natl Cancer Inst 2005;97:188e94. Robinson DW. The hazards of surgery in irradiated tissue. AMA Arch Surg 1955;71(3):410e8. Haouimi A, Gaillard F et al. Peritoneal metastases. Radiopaedia. https://radiopaedia.org/articles/ peritoneal-metastases [Accessed April 2019]. Schorg JO, McCann C, Del Carmen MG. Surgical debulking of ovarian cancer: what difference does it make? Rev Obstet Gynecol 2010;3:111e7. Lee DJ, Sagar PM, Sadadcharam G, Tan KY. Advances in surgical management for locally recurrent rectal cancer: How far have we come? World J Gastroenterol 2017;23:4170e80. Wichmann MW, Maddern G, editors. Palliative surgery. New York: Springer; 2014. Hanna J, Blazer DG, Mosca PJ. Overview of palliative surgery: principles and priorities. J Palliat Care Med 2:132. Krouse RS, Nelson RA, Farell BR, et al. Surgical palliation at a cancer center: incidence and outcomes. Ach Surg 2001;136:773e8. American Society for Clinical Oncology (ASCO). Cancer.Net. Reconstructive surgery. 2018. https://www. cancer.net/navigating-cancer-care/how-cancer-treated/ surgery/reconstructive-surgery. Ludwig KK, Neuner J, Butler A, et al. Risk reduction and survival benefit of prophylactic surgery in BRCA mutation carriers, a systematic review. Am J Surg 2016;212(4):660e9.
References
[26] Provenzale D, Kowdley KV, Arora S, Wong JB. Prophylactic colectomy or surveillance for chronic ulcerative colitis? A decision analysis. Gastroenterology 1995;109:1188e96. [27] Lakatos PL, Lakatos L. Risk for colorectal cancer in ulcerative colitis: changes, causes and management strategies. World J Gastroenterol 2008;14:3937e47. [28] Silberman H, Silberman AW, editors. Principles and practice of surgical oncology. Philadelphia PA: LWW/Wolters Kluwer; 2010. [29] American Society for Clinical Oncology (ASCO). Cancer.Net. Lung cancer e Non-small cell. https://www. cancer.net/cancer-types/lung-cancer-non-small-cell/ treatment-options [Accessed April 2019]. [30] Agzarian J, Fahim C, Shargall Y. The use of roboticassisted thoracic surgery for lung resection: a comprehensive systematic review. Semin Thorac Cardiovasc Surg 2016;28(1):182. Epub 2016 Feb 9. [31] Midthun DE. Overview of the initial treatment and prognosis of lung cancer. UpToDate, Topic 4639 Version 49.0, last updated March 2019. [32] Leong S, Ju H, Marshall H, Bowman R, et al. Electromagnetic navigation bronchoscopy: a descriptive analysis. J Thorac Dis 2012;4:173e85. [33] MD Anderson Cancer Center. Colon Cancer treatment algorithm. 2018. https://www.mdanderson.org/ content/dam/mdanderson/documents/forphysicians/algorithms/cancer-treatment/catreatment-colon-web-algorithm.pdf. [34] Sakorafas Gh, Safioleas M. Breast cancer surgery: an historical narrative. Part II. 18th and 19th centuries.
[35]
[36]
[37]
[38]
[39]
[40]
[41] [42]
353 Eur J Cancer Care 2010;19(1):6e29. https://doi.org/ 10.1111/j.1365-2354.2008.01060.x. Zdenkowski N, Butow P, Tesson S, Boyle F. A systematic review of decision aids for patients making a decision about treatment for early breast cancer. Breast 2016;26:31e45. Boyages J, Delaney G, Taylor R. Predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis. Cancer 1999;85(3):616e28. Alemzadeh H, Raman J, Leveson N, et al. Adverse events in robotic surgery: a retrospective study of 14 years of FDA data. PLoS One 2016;11(4):e0151470. Franklin A, Campbell J, Pokala N. Hemorrhagic complications of robot-assisted laparoscopic partial nephrectomy for renal masses. J Clin Oncol 2016; 34(2_Suppl. l). 621-621. The Joint Commission, Division of Healthcare Improvement. Potential risks of robotic surgery. QuickSafety 2014;(3). https://www.jointcommission.org/ assets/1/23/Quick_Safety_Issue_Three_June_2014. pdf. Lepton K. Robotic surgery e advantages and disadvantages. Future Technology 500. February 2011. http://www.futuretechnology500.com/index.php/ future-medical-technology/robotic-surgeryadvantages-and-disadvantages. Warren H, Dasgupta P. The future of robotics. Investig Clin Urol 2017;58(5):297e8. Whalen G. Principles of surgical oncology. In: Cancer concepts: a guidebook for the non-oncologist. Worcester, MA: University of Massachusetts Medical School; 2016. https://doi.org/10.7191/cancer_concepts.1022.