Treatment of Cancer:

Surgical Principles

Alexandre Malek, MD, MSc.

Clinical assistant professor of surgery
Surgery clerkship director
Gilbert and Rose-Marie Chaghoury School of Medicine
Learning Objectives
• Understand general principles of tumor biopsy

• Identify the importance of staging before and after surgical intervention

• Review principles of cancer resection

i. Complete excision – R resection
ii. Lymphatic drainage assessment and resection
iii. Metastatic tumor resection
iv. Oncologic resection vs. Functional preservation / cosmesis

• Know what palliative surgical treatment is

• Highlight the role of reconstructive surgery in surgical oncology

Biopsy

The intent of biopsy of a tumor is to obtain a representative sample to establish a diagnosis that
can guide treatment
Biopsy
o We can also describe biopsy by the approach we use:
• Laparoscopic vs. Open
• Image guided
• Endoscopic

o And according to the technique used:

Surgical
Fine needle aspiration biopsy
Core needle biopsy
Punch biopsy
Shave biopsy
Biopsy
o Diagnosis Tumor biology

o The biopsy can be:

• Incisional where a small sample is excised
• Excisional where the entire tumor is removed

o Whether incisional or excisional the biopsy

SHOULD NOT compromise further treatment
options and should not negatively impact
prognosis.
Biopsy

• Biopsies have to be well marked and

oriented

• The pathologist can identify if margins are

involved with tumor and the distance
between tumor cells and the edge of the
specimen (Margin)
Staging
Staging
Principles of Cancer Resection

• Surgical resection or removal of tumors is still one of most important and effective treatment
options for many solid tumors

• The surgical approach depends on the particular tumor biology and is not the same for all tumors

• Surgical resection should not leave tumor cells behind and resection margins should be free of
tumor

• The aim is to cure and prevent disease recurrence

Cancer Resection

Curative resection refers to the absence of tumor after surgical treatment.

American Joint Committee on Cancer (AJCC) and the International Union Against Cancer (UICC)
classify resection status based on residual (R) left behind:
X: The presence of residual tumor cannot be assessed.
R0: No residual tumor.
R1: Microscopic residual tumor.
R2: Macroscopic residual tumor
Cancer Resection
Cancer Resection

• All macroscopic and microscopic tumor needs to be removed

• What about the margin? How far should we resect away from visible tumor?

• In cutaneous melanoma multiple RCT showed no significant difference in recurrence rates or

overall survival between 2 and 4 cm resection margins
Cancer Resection
Cancer Resection

o Wide resection margins are not always simple or safe to achieve, examples:

• Tumors in the brain or spinal cord

• Tumors adjacent to vital structures such as major vessels or nerves
• Tumors whose wide resection lead to major impairment in function or cosmetic appearance
• Rectal tumor: incontinence and life-long stoma
• Extremity tumors: amputations
• Laryngeal tumor: speech and swallowing impairment
• Breast cancer: asymmetry and appearance
Cancer Resection

o Alternatives:
• Improve accuracy of resection: stereotactic brain surgery, ultra-sound guided liver resection.
• Neo-adjuvant therapy: treatment before surgical resection to “shrink” down the tumor and
facilitate resection: examples, rectal cancer, gastric cancer, osteo-sarcoma

o Consider non-surgical alternatives:

• Radiation and/or chemotherapy: examples Anal cancer, squamous cell CA esophagus, head and
neck

o Best results are obtained in high volume surgical centers

Cancer Resection
o Is there value in radical surgery when microscopic disease is left behind?
• Most cancers NO, example: patient with gastric cancer or pancreatic cancer will not be subjected
to curative radical resection if a small (1-2 mm) metastasis is found.

• Whereas major surgery can be considered in

1. Ovarian cancer: primary cyto-reductive surgery with pre and post chemotherapy
2. Primary peritoneal malignancies (Pseudo-myxoma peritoni) cyto-reductive surgery + heated
intra-peritoneal chemotherap
Cancer resection - lymphatics

o Tumors grow in size and can spread throughout the body by:

• Local spread: peritoneal carcinomatosis, renal cell cancer and intravenous tumor thrombus

• Lymphatic spread: breast cancer, melanoma, colon and rectal cancer

• Hematogenouos spread: sarcomas

• Combination
Cancer resection - lymphatics

William halsted - Surgeon

• Surgeons for more than a century recognized the importance of lymphatic spread in tumor
progression

• Advocated radical resection with lymph node dissection

Cancer resection - lymphatics
o Advantages of Lymph node dissection
• More accurate TNM staging
• Improves cure rate
• Reduces risk of local or regional recurrence
• Guide adjuvant therapy
• Determine prognosis

o Disadvantages
• Serious morbidity: infection, nerve damage, extremity swelling
Cancer resection – metastasis
o Cancer cure can be achieved by multi-modality treatment including surgical resection of
metastases

o Examples include:
• Colorectal liver metastasis
• Colorectal lung metastasis
• Neuro-endocrine tumors
Cancer resection – balancing

o Balance between oncologic principles of cancer and lymphatic resection and organ preservation
for function and quality of life

o Therapy effects (positive as well as negative) have to be studied rigorously via Randomized
controlled clinical trials
Cancer resection – balancing
• Radical Mastectomy

• Modified Radical Mastectomy (preservation of the

Pectoralis major and minor muscle)

• Breast conservation surgery (local excision of the

tumor + radiation therapy)
Cancer Surgery - Palliation
o The role of surgery in cancer management is not only restricted to biopsy and curative resection
but extends to palliation.

o Palliation means alleviating symptoms related to the tumor without an intent to cure

o Examples include resecting an obstructing colonic tumor even if the patient has unresectable
liver metastasis, placing a feeding tube, etc…
Cancer Surgery - reconstruction
o Reconstruction is an integral part of surgical oncology and is intended to restore function and
improve cosmetic results after extensive resection

o It can include simple interventions such a skin graft to complicated tissue flaps with micro-
vascular anastomoses to organ transplantation

o This often requires collaboration between multiple surgical teams of different specialties including
plastic and reconstructive surgery
Cancer Surgery - reconstruction
Cancer Surgery - reconstruction
Thank You