Principles of cancer surgery

Principles of cancer surgery

For most solid tumours, surgery remains the definitive treat - ment and the only realistic hope of cure. However, surgery has many roles in cancer treatment from diagnosis, prevention, removal of primary disease, removal of metastatic disease, reconstruction through to palliation of symptoms. Role in diagnosis and staging In most, but not all, patients the diagnosis of cancer has been confirmed by biopsy before definitive surgery is carried out; - however, occasionally a surgical procedure is required to make the diagnosis, e.g. in renal cell cancer where not all patients with a renal mass will undergo a biopsy , prior to definitive surgery to remove and diagnose the tumour as either malignant or benign. Laparoscopic surgery is used as part of the staging of intra-abdominal malignancy , particularly oesophageal and gastric cancer. By this means it is often possible to diagnose - widespread peritoneal disease and small liver metastases that may have been missed on cross-sectional imaging. Laparoscopic

Disadvantages Less con /f_i dent and less articulate members of the team may not be able to express their views, even though their views may be extremely important May become a rubber-stamping exercise in which the class solutions implied by guidelines are applied to disparate individuals Decisions are made in the absence of patients and their carers Clinicians are able to avoid having to take responsibility for their decisions and their actions – ‘corporate responsibility’ Time-consuming and resource intensive: takes multiple busy clinicians away from clinical practice for hours at a time

Potential members of the cancer multidisciplinary team /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ultrasound is a particularly useful adjunct for the diagnosis of intrahepatic metastases. Other examples of when surgery is central to the diagnosis of cancer include orchidectomy , in a patient suspected of testicular cancer; lymph node biopsy in a patient with lymphoma; and sentinel node biopsy in melanoma and breast cancer. Removal of primary disease Radical surgery for cancer involves removal of the primary tumour and as much of the surrounding tissue and lymph node drainage as possible in order not only to ensure local control but also to prevent spread of tumour through the lymphat ics. Although the principle of local control is still extremely important, it is now recognised that ultra-radical surgery probably has little e ff ect on the development of metastatic disease, as evidenced by the randomised trials of radical versus simple mastectomy for breast cancer. It is important, however, to appreciate that high-quality , meticulous surgery taking care not to disrupt the primary tumour at the time of excision is of the utmost importance in obtaining a cure in localised disease and in preventing local recurrence. Removal of metastatic disease Under certain circumstances surgery for metastatic disease may be appropriate. This is particularly true for liver metasta ses arising from colorectal cancer where successful resection of all detectable disease can lead to long-term survival in about one-third of patients. With multiple liver metastases, it may still be possible to take a surgical approach by using in situ ablation with cryotherapy or radiofrequency energy . Another situation in which surgery may be curative in metastatic disease is that of pulmonary resection for isolated lung metastases, particularly from renal cell carcinoma. In many cases surgery is not appropriate for cure but may be valuable for palliation. A good example of this is the patient with a symptomatic primary tumour who also has distant metastases, e.g. a patient with a large, symptomatic renal cell cancer but di ff use metastatic disease. In this case, removal of the primary will increase the patient’s quality of life but will have little e ff ect on the ultimate outcome.

Site-specialist surgeon Surgical oncologist Plastic and reconstructive surgeon Clinical oncologist/radiotherapist Medical oncologist Diagnostic radiologist Interventional radiologist Palliative care physician Pathologist Speech therapist Physiotherapist Prosthetist Clinical nurse specialist (rehabilitation, supportive care) Clinical trial team representative Palliative care nurse Social worker/counsellor Medical secretary/administrator Multidisciplinary team coordinator

Principles of cancer surgery

For most solid tumours, surgery remains the definitive treat - ment and the only realistic hope of cure. However, surgery has many roles in cancer treatment from diagnosis, prevention, removal of primary disease, removal of metastatic disease, reconstruction through to palliation of symptoms. Role in diagnosis and staging In most, but not all, patients the diagnosis of cancer has been confirmed by biopsy before definitive surgery is carried out; - however, occasionally a surgical procedure is required to make the diagnosis, e.g. in renal cell cancer where not all patients with a renal mass will undergo a biopsy , prior to definitive surgery to remove and diagnose the tumour as either malignant or benign. Laparoscopic surgery is used as part of the staging of intra-abdominal malignancy , particularly oesophageal and gastric cancer. By this means it is often possible to diagnose - widespread peritoneal disease and small liver metastases that may have been missed on cross-sectional imaging. Laparoscopic

Disadvantages Less con /f_i dent and less articulate members of the team may not be able to express their views, even though their views may be extremely important May become a rubber-stamping exercise in which the class solutions implied by guidelines are applied to disparate individuals Decisions are made in the absence of patients and their carers Clinicians are able to avoid having to take responsibility for their decisions and their actions – ‘corporate responsibility’ Time-consuming and resource intensive: takes multiple busy clinicians away from clinical practice for hours at a time

Potential members of the cancer multidisciplinary team /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ultrasound is a particularly useful adjunct for the diagnosis of intrahepatic metastases. Other examples of when surgery is central to the diagnosis of cancer include orchidectomy , in a patient suspected of testicular cancer; lymph node biopsy in a patient with lymphoma; and sentinel node biopsy in melanoma and breast cancer. Removal of primary disease Radical surgery for cancer involves removal of the primary tumour and as much of the surrounding tissue and lymph node drainage as possible in order not only to ensure local control but also to prevent spread of tumour through the lymphat ics. Although the principle of local control is still extremely important, it is now recognised that ultra-radical surgery probably has little e ff ect on the development of metastatic disease, as evidenced by the randomised trials of radical versus simple mastectomy for breast cancer. It is important, however, to appreciate that high-quality , meticulous surgery taking care not to disrupt the primary tumour at the time of excision is of the utmost importance in obtaining a cure in localised disease and in preventing local recurrence. Removal of metastatic disease Under certain circumstances surgery for metastatic disease may be appropriate. This is particularly true for liver metasta ses arising from colorectal cancer where successful resection of all detectable disease can lead to long-term survival in about one-third of patients. With multiple liver metastases, it may still be possible to take a surgical approach by using in situ ablation with cryotherapy or radiofrequency energy . Another situation in which surgery may be curative in metastatic disease is that of pulmonary resection for isolated lung metastases, particularly from renal cell carcinoma. In many cases surgery is not appropriate for cure but may be valuable for palliation. A good example of this is the patient with a symptomatic primary tumour who also has distant metastases, e.g. a patient with a large, symptomatic renal cell cancer but di ff use metastatic disease. In this case, removal of the primary will increase the patient’s quality of life but will have little e ff ect on the ultimate outcome.

Site-specialist surgeon Surgical oncologist Plastic and reconstructive surgeon Clinical oncologist/radiotherapist Medical oncologist Diagnostic radiologist Interventional radiologist Palliative care physician Pathologist Speech therapist Physiotherapist Prosthetist Clinical nurse specialist (rehabilitation, supportive care) Clinical trial team representative Palliative care nurse Social worker/counsellor Medical secretary/administrator Multidisciplinary team coordinator

Principles of cancer surgery

For most solid tumours, surgery remains the definitive treat - ment and the only realistic hope of cure. However, surgery has many roles in cancer treatment from diagnosis, prevention, removal of primary disease, removal of metastatic disease, reconstruction through to palliation of symptoms. Role in diagnosis and staging In most, but not all, patients the diagnosis of cancer has been confirmed by biopsy before definitive surgery is carried out; - however, occasionally a surgical procedure is required to make the diagnosis, e.g. in renal cell cancer where not all patients with a renal mass will undergo a biopsy , prior to definitive surgery to remove and diagnose the tumour as either malignant or benign. Laparoscopic surgery is used as part of the staging of intra-abdominal malignancy , particularly oesophageal and gastric cancer. By this means it is often possible to diagnose - widespread peritoneal disease and small liver metastases that may have been missed on cross-sectional imaging. Laparoscopic

Disadvantages Less con /f_i dent and less articulate members of the team may not be able to express their views, even though their views may be extremely important May become a rubber-stamping exercise in which the class solutions implied by guidelines are applied to disparate individuals Decisions are made in the absence of patients and their carers Clinicians are able to avoid having to take responsibility for their decisions and their actions – ‘corporate responsibility’ Time-consuming and resource intensive: takes multiple busy clinicians away from clinical practice for hours at a time

Potential members of the cancer multidisciplinary team /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF ultrasound is a particularly useful adjunct for the diagnosis of intrahepatic metastases. Other examples of when surgery is central to the diagnosis of cancer include orchidectomy , in a patient suspected of testicular cancer; lymph node biopsy in a patient with lymphoma; and sentinel node biopsy in melanoma and breast cancer. Removal of primary disease Radical surgery for cancer involves removal of the primary tumour and as much of the surrounding tissue and lymph node drainage as possible in order not only to ensure local control but also to prevent spread of tumour through the lymphat ics. Although the principle of local control is still extremely important, it is now recognised that ultra-radical surgery probably has little e ff ect on the development of metastatic disease, as evidenced by the randomised trials of radical versus simple mastectomy for breast cancer. It is important, however, to appreciate that high-quality , meticulous surgery taking care not to disrupt the primary tumour at the time of excision is of the utmost importance in obtaining a cure in localised disease and in preventing local recurrence. Removal of metastatic disease Under certain circumstances surgery for metastatic disease may be appropriate. This is particularly true for liver metasta ses arising from colorectal cancer where successful resection of all detectable disease can lead to long-term survival in about one-third of patients. With multiple liver metastases, it may still be possible to take a surgical approach by using in situ ablation with cryotherapy or radiofrequency energy . Another situation in which surgery may be curative in metastatic disease is that of pulmonary resection for isolated lung metastases, particularly from renal cell carcinoma. In many cases surgery is not appropriate for cure but may be valuable for palliation. A good example of this is the patient with a symptomatic primary tumour who also has distant metastases, e.g. a patient with a large, symptomatic renal cell cancer but di ff use metastatic disease. In this case, removal of the primary will increase the patient’s quality of life but will have little e ff ect on the ultimate outcome.

Site-specialist surgeon Surgical oncologist Plastic and reconstructive surgeon Clinical oncologist/radiotherapist Medical oncologist Diagnostic radiologist Interventional radiologist Palliative care physician Pathologist Speech therapist Physiotherapist Prosthetist Clinical nurse specialist (rehabilitation, supportive care) Clinical trial team representative Palliative care nurse Social worker/counsellor Medical secretary/administrator Multidisciplinary team coordinator