Treatment - Surgery

LOCOREGIONAL THERAPY

Optimally, antitumor treatment should eradicate all manifestation of the disease completely and perma-nently. The cancer cell is regarded as an offending foreign "organism" to be removed or destroyed by various therapeutic modalities. Surgery and radiotherapy are the principal local therapies for cancer.

Surgery

Historically cancer has been a surgical disease. During the first part of this century it was the only cancer treatment available. Surgical excision is still the current principal curative therapy, especially for cancers at accessible sites that can be detected early and excised completely. The location and extent of the tumor rather than its type limit the surgeon. The operative risks of anesthesia and surgery, and the morbidity after the procedure must all be taken into account.

With some tumors systemic speed is thought to occur early with micrometastatic deposits beyond the tumor field. Regional lymph node involvement be-comes an indicator of metastatic activity with adverse survival. Stage II breast cancer or Duke's C colon cancer are examples. Here surgery of the primary tumor is becoming less radical, with, for example, a lumpectomy with breast radiotherapy producing re-sults as good as with radical or modified radical mastectomy in breast cancer. In this setting regional node dissection is a staging procedure in addition to providing regional control. Nontherapeutic staging procedures are also used, such as laparotomy for Hodgkin's disease and other lymphomas and second--look procedures for ovarian and colon cancer.

Laser surgery, often with an operating micro-scope, is becoming a useful approach in certain settings. Blood dyscrasias, seriously ill patients, and palliation of obstructing esophageal and tracheobron-chial lesions through a rigid endoscope are examples of its use. The tissue is vaporized and small blood vessels and lymphatics are sealed with a fine incision and minimal damage to adjacent tissue. The con-trolled depth of penetration helps avoid perforation in surgery of the head and neck and tracheobronchial tree. Laser surgery through a colposcope can provide control of early uterine cervical neoplasms, as can cryosurgery.

Surgery can achieve cytoreduction before administration of chemotherapy by debulking tumors such as Wilms' tumor, ovarian cancer or Burkitt's lymphoma.

Advances in the use of myocutaneous flaps and microvascular anastomotic techniques have allowed reconstructive surgery to provide functional, esthetic and psychological benefits after both major surgical resections and primary radiotherapy. Surgery can also stabilize weight-bearing bones that have been weakened by metastatic disease.

Surgery can also play a role in cancer prevention. Examples include the removal of premalignant cervical or skin lesions (dysplastic nevi or actinic keratoses); colectomy in familial polyposis, non-polyposis familial colon cancer or ulcerative colitis; prophylatic mastectomy for women with very high risk of breast cancer; oophorectomy for familial ovarian cancer; orchiopexy or orchiectomy for undescended testes not corrected before puberty; and thyroidectomy in familial, multiple endocrine neoplasia type II to prevent medullary thyroid cancers.

Radical surgery in the head and neck region, pelvic exenteration, and hemicorporectomy are less often used as a last resort for locally advanced primary or recurrent tumors. Advances in prosthetics and reconstructive surgery of the head and neck and pelvis may make these radical procedures more acceptable. Surgical resection of metastatic disease with intent to cure is occasionally appropriate with slow growing, solitary metastases, such as pulmonary metastases from osteosarcoma or melanoma or solitary liver metastases from colorectal cancer. Surgery may be used to palliate metastatic disease by alleviating symptoms and improving quality of life through relieving pain, hemorrhage or obstruction.

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