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However, the concept of 'en bloc' surgery has been strongly debated, since the observation, even for limited disease, of remote metastases and has resulted in surgical procedures in better conformity with the tumour biology.

Quite often, the mutilating surgery does not cure the patient because the cancer disease has already spread outside of the therapeutic possibilities offered by surgery (or radiotherapy).

On the contrary, randomised studies have demonstrated that less radical surgical procedures offered identical survival results. Nevertheless, even taking this into account, surgery remains the major cancer therapy in approximately 80% of cases.

The example of breast cancer

In breast cancer, the presence of invaded axillar nodes is the manifestation of the metastatic diffusion of cancer cells. The complete removal of all lymph vessels and nodes is of no therapeutic utility: nodes are more the reflection of the metastatic process than the agents of its propagation.

Randomised studies have demonstrated that mammary lumpectomy (tumour ablation with a small security limit) when followed by complementary radiotherapy has the same efficiency as radical mastectomy. The major prognostic factor is the state of satellite nodes. The dimension of the local surgical resection does not modify risks in terms of local control or remote metastases.

When nodes are positive or if the tumour is poorly differentiated, adjuvant chemotherapy or hormonotherapy play an important therapeutic role. The local surgical procedure is secondary in these cases.

Compilation of three large randomised trials demonstrating the equivalence of radical mastectomy (with lymphadenectomy)
and single lumpectomy (with lymphadenectomy) followed by radiotherapy.
The absence of radiotherapy increases the number of local relapses without influencing the global survival.

Other examples

Several major surgical procedures have been reduced in relationship with efficient adjuvant therapies.

For instance, formerly, the presence of lumbo-aortic adenopathies in testicular cancer induced node excision with the risk of anejaculation. Nowadays this surgery is only proposed when persistent adenopathies exist after chemotherapy (and in certain cases when tissue is active according to PET-Scan). There is, therefore, a significant limitation in morbidity.

High Intensity Focused Ultrasound

Another to treat localized cancers by a pseudo-surgical method is the use of High Intensity Focused Ultrasounds.

Due to the high intensity a complete destruction of the glandular tissue due to coagulation necrosis is obtained, reaching the capsule and the periprostatic fat.

HIFU is nowadays mainly used for localized prostate cancer.