| Ch 7 | Page 5 / 12 | |
| Cancer surgery |
Radical surgery | |
This concept is based on tumour spread rendering impossible for the surgeon to be certain of the excision limits: for this reason, radical surgery should remove, in one piece, the tumour, a large portion of the organ bearing the tumour, the connective tissue around it together with the lymph vessels and regional lymph nodes. The great probability of extension to regional nodes implies the surgical removal of those satellite nodes, even if, macroscopically, they seem unharmed. At least the first lymph node level should be removed and all the connective tissue between the tumour and these nodes where the lymph vessels are found.
For the surgeon, the excision limits are evaluated as the distance between the tumour and the zone where, statistically, no tumour is found.
In difficult situations, the determination of this border could be significantly improved by the precise marking of the excision limits (by china ink for instance) and the performance of extemporaneous histological examinations. A trust-based dialogue should be established between the surgeon and the pathologist during the operative procedure in order to define a satisfactory excision.
Here is a non exhaustive list of some radical excisions:
For digestive tumours, such interventions are performed:
- radical oesophagectomy for oesophageal cancer,
- total or large gastrectomy, with complete node dissection,
- right hemicolectomy for caecum cancer with lymphadenectomy up to colic artery origin.
For mammary tumours, radical mastectomy is still performed (or Halstedt intervention or Patey intervention which respects the pectoral muscle), with ablation of the mammary gland, the skin, the axillary wall and cellular tissue of the armpit. Until they benefit from a breast reconstruction surgery, patients require to wear a mammary prosthesis in their bra.
.In gynaecological surgery, an enlarged colpo-hysterectomy with bilateral iliac lymphadenectomy is the standard surgery for cervix uteri or corpus uteri cancer.
In Urology, for treating testicular cancer, an orchidectomy through an inguinal approach should be performed, including the ligature of spermatic cord as high as possible, in order to avoid any remote dissemination. The scrotum approach would be a mistake.
For treating bladder carcinoma, in male patients, cystectomy is a radical prostato-cystectomy with a possible ileal bladder reconstruction. The external sphincter is preserved and the patient can re-educate himself and obtain correct bladder autonomy (occasionally with night incontinence).
Among women, such an artificial bladder is difficult to realise since the external sphincter is difficult to isolate. Very often, an external derivation is mandatory with a trans-ileal pseudo-bladder called a Bricker intervention and the use of urinary external appliance. (Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North America. 1950; 30: 1511-2).
The good good positionning of the stomy, its regular maintenance and the patient's education necessitate the presence of a stomatherapy nurse. Over and above their purely technical role, these nurses offer help and psychological support which are essential when facing such mutilation.
However, this concept is often difficult to apply, thus explaining many surgical failures.
For ovarian carcinoma, which is clinically manifested by a diffuse peritoneal carcinomatosis, the importance of excision and of residual tumours left after the first surgical procedure, is the major prognostic factor just after staging. Thus, an optimal resection is the goal of such surgery.
The surgeon’s aggressiveness, the correct patient preparation (intestinal preparation) and the duration of the surgical procedure have a positive influence on survival. However, it is clear that a macroscopically complete excision of any tumour lesion does not provide the assertion that no microscopic lesions remain. For these reasons, some surgeons have proposed a complete excision of the parietal and parenchymentous peritoneum: however this excision induced many complications with difficult operative recovery which delayed the mandatory adjuvant chemotherapy. Such surgical procedures have, therefore, been abandoned.
For tumours where complete excision was impossible at the time of first surgery, an interim laparotomy with complete tumour excision, if the tumour responds well to chemotherapy, improves patient survival.
For prostate cancer, the radical prostatectomy will be performed but at the same time the surgeon will try to protect erection nerves and urinary continence. Thus, quite often, the limits may be pathological and an adjuvant local radiotherapy is necessary.
In Head and Neck surgery, the anatomical limits are often very close to the excision limits. Complementary radiotherapy is therefore frequent.
Our discussion does not concern necessary lymphadenectomy carried out because of clinically invaded nodes and for which the excision is presumed to have a therapeutic value.
The goal of systematic lymphadenectomy is to determine the evolutive potential of the cancer. Node invasion is one of the best prognostic factors: the more positive nodes are, the poorer the prognosis.
Curage is carried out starting from the tumour and according to the general observation of successive node invasion from one level to the next. 'Skip metastases' (metastases that 'jump' a level) are rare no matter what type of cancer is involved.
In general, lymphadenectomy only concerns the first levels, since, beyond them, the cancer is considered as already potentially metastatic. The surgical excision of invaded nodes does not seem to modify prognosis (no clear clinical study in favour of this attitude), but will provoke major negative consequences.
In order to avoid useless sequellae (noticeable lymphoedema of the arm or the leg), research has been carried out to find the minimal tumour volume beneath which the nodes are generally not invaded, thus node dissection becomes futile (for instance: mammary tumour below 5 mm or micro-invasive cervix carcinoma).
In mammary surgery, study of the 'sentinel node' (i.e. the first node level) is most interesting with the use of detection techniques either by colorimetry (Evans Blue) or by radio-colloid. There is a major deteriorating prognostic value of positive nodes (cf. classification)
The study of adenopathies (particularly of capsule invasion which s
ignifies the invasion of adjacent tissue resulting in node fixation) is of utmost interest in Head and Neck cancer. The size of the adenopathies reduces the efficiency of radiotherapy and surgical excision is, therefore, often performed.
For certain cancers where surgery is mutilating (such as radical prostatectomy or cystectomy), the first surgical time is the node sentinel biopsy with an extemporaneous study of the specimen: if there are positive nodes, radical surgery should be discussed (great risk of remote metastases).
 |
