Cancer Surgery: Information & Cancer Surgery Specialists

A prerequisite for an optimal treatment plan is knowledge of

• the type of tumor,
• the extent of the cancer, and
• the extent of metastasis (tumor stage, tumor staging).

Findings from molecular biology research and technological advancements have a significant impact on modern oncological surgery. Accurate diagnosis at the start of any cancer treatment is therefore crucial.

Commonly used diagnostic procedures include, for example,

• CT
• MRI
• Angiography
• Ultrasound
• Contrast-enhanced sonography
• Endoscopy
• Histology

Depending on the results of the diagnostic tests, cancer treatment may consist of

• chemotherapy,
• radiation therapy, or
• surgical removal of the tumor, or
• a combination of these three treatment options

.

Tumor surgery may be performed first and/or followed by chemotherapy and/or radiation therapy. This is referred to as preoperative (neoadjuvant) or postoperative (adjuvant) chemotherapy or radiation therapy.

The primary goal of tumor surgery is to cure the cancer while maintaining the highest possible quality of life. Therefore, oncological surgery usually aims to completely remove the tumor and the surrounding lymph nodes.

However, the surrounding healthy tissue must be spared as much as possible. The treatment should also minimize the risk of the tumor returning (recurrence) as much as possible.

Just a few years ago, achieving a cure through tumor surgery was difficult. Since then, medical science has gained a better understanding of cancer, and surgical techniques have been further refined. As a result, tumor surgery is now a crucial component of cancer treatment.

Minimally invasive techniques are now increasingly being used in surgical oncology.

If the cancer is still in an early stage, it can often be cured through surgical oncology alone.

In cases of advanced cancer, combined treatment approaches involving tumor surgery, radiation therapy, and chemotherapy are generally required to treat the tumor.

Curative Tumor Surgery

Curative tumor surgery aims to cure the patient—that is, to remove the tumor while preventing recurrence.

Curative tumor surgery aims to completely cure the patient and prevent recurrence (regrowth of the tumor). Curative tumor surgery generally requires that tumor growth be locally confined.

Furthermore, it must be possible to remove the tumor from healthy tissue. This means that, for safety reasons, a portion of the surrounding healthy tissue is also removed along with the tumor.

It must be possible to reconstruct the function of the removed organs (e.g., via a colostomy).

In the past, this curative therapeutic approach led to increasingly extensive surgical procedures. In some cases, this was accompanied by a reduced quality of life and increased morbidity.

For this reason, the current approach in oncological surgery combines less invasive procedures with adjuvant therapies. This therapeutic principle is reflected, for example, in breast-conserving surgery combined with adjuvant radiation therapy. It can serve as an alternative to a radical mastectomy (complete removal of the breast).

Cytoreductive Tumor Surgery

In oncological surgery, cytoreductive tumor surgery aims to create a favorable starting point for subsequent therapies.

The goal is to remove as much tumor tissue as possible (known as reducing the tumor burden). This is intended to increase the chances of destroying the remaining, unresected tumor tissue through radiation therapy and/or chemotherapy.

This procedure is also known as debulking. It is used only when other effective treatment options are available in addition to tumor surgery. Debulking is used, for example, in cases of advanced ovarian cancer.

Preventive Tumor Surgery

Molecular biological diagnostics are increasingly able to identify individuals who are currently healthy but may develop cancer in the future.

For example, mutations in the BRCA1 or BRCA2 genes increase the likelihood that affected women will develop breast cancer (mammary carcinoma). Depending on the genetic mutation, treatment may involve

• close monitoring of the patient or
• preventive removal of the organ or body part 

.

Palliative Surgical Treatment

Palliative tumor surgery is used for incurable tumors. Its goal is to improve the patient’s quality of life by eliminating or alleviating symptoms of the tumor or concomitant conditions.

It can also be performed prophylactically to prevent complications from metastasis and to maintain a symptom-free state for as long as possible.

This includes

• removal of the primary tumor and, rarely, of metastases,
• tumor-preserving procedures,
• endoscopic procedures or interventions that prepare the patient for supportive care (e.g., port implantation).

Palliative
tumor surgery is intended to improve the patient’s quality of life © Chinnapong | AdobeStock

In general, only solid cancers can be treated surgically. Solid tumors are initially localized, but they can later spread to surrounding tissue or even metastasize.

Solid tumors can originate in various internal organs and may be benign or malignant.

In contrast, cancers of the lymphatic system or the hematopoietic system, for example, cannot be treated with oncological surgical methods.

Surgical oncology is used when

• there is a possibility of completely removing the cancer through surgery,
• this can resolve or alleviate physical symptoms or impairments (e.g., limited food intake, intestinal obstruction), or
• it allows for the removal of secondary tumors (metastases).

In tumor surgery, tumors of the digestive tract (e.g., colorectal cancer) and tumors of the thyroid gland are particularly common targets for surgical treatment.

Oncological surgery is also responsible for port implantations. A port is a permanent access point into the body that is needed, for example, during chemotherapy or for pain management.

Cancer Surgery: Thyroid Cancer

In oncological surgery, thyroid cancer is usually treated by removing

• the entire thyroid gland and
• the lymph nodes located next to the trachea and esophagus.

Cancer Surgery: Esophageal Tumors

In cases of esophageal cancer, it is usually necessary to open the chest and abdominal cavities. If the esophagus must be removed, it can often be reconstructed using parts of the stomach.

Cancer Surgery: Stomach Cancer (Gastric Carcinoma)

In cases of gastric carcinoma, it is very often necessary to remove the entire stomach along with the affected lymph nodes.

As a result, patients must adjust their diet after a total gastrectomy. They can only eat smaller meals, but must do so several times a day.

Cancer Surgery: Pancreatic Cancer (Pancreatic Carcinoma)

Surgery on the pancreas is technically among the most challenging procedures in oncological surgery. Common procedures for pancreatic cancer include

• removal of the “head” of the pancreas and
• left pancreatectomy.

In a left pancreatic resection, the “tail” of the pancreas is removed. To remove the entire tumor in the head of the pancreas, the Whipple procedure involves removing not only the pancreatic head but also

• the duodenum,
• the gallbladder,
• the common bile duct, and
• one-third of the stomach

are also removed.

In a total pancreatectomy, the entire pancreas is removed along with

• the duodenum,
• the spleen,
• the gallbladder, and
• the lower part of the bile duct

.

Cancer Surgery: Colorectal Cancer (Colon Cancer, Rectal Cancer)

Tumor surgery is very commonly used in the treatment of colon cancer (colon carcinoma). During this procedure, parts of the intestine are removed. In the past, a colostomy was often necessary following intestinal tumor surgery. Today, thanks to improved surgical techniques, this can be avoided in many cases.

A small, locally confined rectal carcinoma (cancer of the rectum) can be removed through oncological surgery. For larger tumors, radiation therapy and chemotherapy are often required prior to surgery. Occasionally, an abdominoperineal resection of the rectum—that is, a complete removal of the rectum and anus—is necessary. In such cases, patients require a colostomy.

Today, many procedures—particularly colorectal cancer surgeries—can be performed using minimally invasive techniques (keyhole surgery).

The successes achieved in this field today are attributable not only to improved surgical techniques but also to the fast-track concept (fast-track surgery). The key pillars of this treatment concept consist of

• thorough preoperative patient counseling,
• modern anesthesia management,
• avoidance of tubes, drains, and catheters in the surgical site,
• optimal pain management,
• rapid resumption of eating, and
• early and intensive mobilization.

Image of tumor lesions in the colon © freshidea | AdobeStock

Cancer Surgery: Metastases

If a tumor is not treated in time, it can form secondary tumors, for example in the liver.

Surgery can be curative if

• the primary tumor or recurrence has been removed or is removable,
• there are no distant metastases that cannot be removed,
• the metastases can be completely removed,
• the surgical risk is low, and
• there are no equivalent treatment options.

In oncological surgery, lung and liver metastases from colorectal carcinomas, soft tissue and bone sarcomas, and hypernephromas are primarily treated. Metastases from other primary tumors can also be removed through tumor surgery.

Tumor Surgery: Lymph Node Removal

Prophylactic lymph node removal (elective lymph node dissection)

As the tumor grows larger, the likelihood that cancer cells are present in the lymph nodes increases. These nodes then drain the affected area of the body (so-called regional lymph nodes).

Cancer cells in the lymph nodes are not always visible to the naked eye. For this reason, the lymph nodes in the tumor’s lymphatic drainage area are also removed, even if there is no clinical or histological evidence of lymph node involvement at the time of the tumor surgery.

This is referred to as an elective lymph node dissection or prophylactic lymph node removal. The reasons for this are

• to prevent the development of a recurrence in the lymph nodes and
• a more accurate assessment of the tumor stage to determine a more precise prognosis.

Therapeutic lymph node removal (selective lymph node dissection)

If the lymph nodes are removed solely because they are either enlarged or already involved, this is referred to as selective lymph node removal. However, this procedure is relatively rare in oncological surgery.

Sentinel lymph node dissection

The concept of sentinel lymph nodes is used for the diagnosis and treatment of malignant tumors. It is used in particular for

• breast cancer,
• melanoma, and
• prostate cancer

.

Sentinel lymph nodes are the lymph nodes located at the very beginning of the lymphatic drainage pathway from a malignant tumor. If tumor cells have already been carried to these sentinel lymph nodes via the lymphatic flow, it is likely that the subsequent lymph nodes are also affected. If the sentinel lymph node is not involved, the subsequent lymph nodes are also likely to be free of cancer.

During sentinel lymph node dissection, not only is the sentinel lymph node removed, but often the entire affected lymphatic tissue as well.