Surgery is the oldest treatment for cancer and, until recently, the only cure for patients with cancer. The excision of a tumor recorded on an Egyptian papyrus dating from 1600 BC may be the earliest use of surgery for cancer. More modern approaches to cancer surgery were described in 1809 when a 22-lb ovarian tumor was successfully excised. In the 1890s, Dr. William S. Halsted, a Johns Hopkins surgeon, developed the radical mastectomy procedure, which became the first surgery commonly used for cancer. Over the last several decades of the 20^th century, advances in surgical technique and a better understanding of the patterns of spread of individual cancers have dramatically changed the surgical treatment of cancer. Modern anesthetic techniques, increased knowledge of antibiotic therapy, and blood component administration have greatly increased the safety of major oncologic surgery and allowed surgeons to perform successful resections for an increased number of patients.

A. Surgical therapy is now used in combination with other forms of treatment. Multimodality therapy has led to more conservative, less radical procedures for some cancers as is seen in the options for the treatment of breast cancer. There is also a trend toward an increased use of more aggressive major operations for other cancers. Complex resections of the pancreas and liver can now be performed with less risk because of increased technology and skill.

B. New technologies may allow for less extensive surgery, with the potential for minimal pain, less use of blood component replacement, decreased hospital stay, and a more rapid recovery. Minimally invasive surgical procedures using laparoscopy, robot-assisted laparoscopy, and video-assisted thoracoscopy are examples of the new techniques that have evolved.

Surgical therapy remains the primary method of treatment of most solid malignancies. In some cases, it is the only chance for cure. It is estimated that more than 90% of patients with cancer have some type of surgical procedure for diagnosis, treatment, or management of the disease and complications.

A major goal of surgical therapy is to resect the entire tumor and to maximize preservation of body function and appearance, if at all possible. Curative resections involve the removal of tumor along with a margin of normal tissue and regional lymph nodes. This type of resection offers the best chance of cure and provides histologic information for prognosis.

A. Growth Rate: Slow-growing tumors generally lend themselves best to surgical treatment because the tumor is more likely to be confined to a
local area. Smaller tumors are also less likely to have spread, and surgical removal is more likely to be curative.

B. Invasiveness: Any cancer cell remaining after surgery constitutes a risk of recurrence or metastasis. A surgical procedure performed for curative intent of cancer would include resection of the entire tumor mass along with a margin of normal tissue to decrease the risk of leaving residual cancer cells. Cancers with extensive invasion into adjacent structures, such as another organ, or invasion into major blood vessels or nerves could preclude a curative surgical resection.

C. Metastatic Potential: Knowledge of the metastatic patterns of individual tumors is crucial in planning the most effective therapy. Tumors that are slow to metastasize are the most amenable to surgery, whereas those that present with advanced disease are less often curable with surgical therapy alone.

D. Tumor Location: The location of the tumor in relation to other structures is a key factor in determining if it can be surgically removed. Superficial and encapsulated tumors are easier to remove than those embedded in inaccessible or delicate areas. The following questions help determine the potential effectiveness of surgical intervention:

1. Does the tumor involve major vessels or structures that cannot be resected?

2. Has the tumor spread to multiple sites?

3. Is it possible to remove the entire tumor along with a margin of normal tissue?

E. Physical Status: The patient’s physical condition may influence the selection of surgery for the treatment of cancer. Careful preoperative assessment involves the evaluation of significant factors that may potentially increase the risk of surgical morbidity and mortality. Deficits should be corrected before surgery whenever possible. Nutritional status often needs corrective measures. A thorough systems assessment and a determination of the presence and severity of other medical conditions factor into the decision to have surgery.

1. The presence and severity of comorbid conditions increase with age. The elderly patient should be treated as aggressively as possible but may need additional preoperative support to be adequately prepared for surgery. Elderly patients are especially at risk for morbidity and mortality if the surgery must be performed as an emergency (eg, emergency surgery to relieve an acute malignant bowel obstruction).

2. A proposed operation may produce physiologic alterations that may be beyond a person’s capabilities. The rehabilitation potential of every patient needs to be evaluated, particularly if the intended surgery will significantly alter normal physiologic function.

F. Quality of Life: Quality-of-life issues must be addressed for potential surgical candidates. Research has shown that some radical surgical procedures are not warranted either because they do not improve the end result or because they interfere unduly with the person’s functional or physiologic well-being. The patient’s unique needs and desires must be considered in the treatment selection process. A particular surgical procedure may be technically feasible, but it may not be the best alternative in terms of quality of life.

A. Diagnosis: A tissue diagnosis is important in the planning of subsequent treatment for specific cancers. The major role of surgery in the diagnosis of cancer is the acquisition of tissue for histologic diagnosis. Various techniques are used to obtain tissue for suspected malignancy.

1. Aspiration biopsy is the removal of cells and tissue fragments by aspiration through a needle that has been guided into the suspect tissue. The material is cytologically analyzed to provide a tentative diagnosis of the presence of malignant cells. Although this is a recognized method of examining cells, major surgical resections may not be performed solely on the basis of the evidence provided by an aspiration biopsy because there is an error rate substantially higher than that of standard histologic diagnostic tests.

2. Needle biopsy is performed by obtaining a core of tissue through a specially designed needle placed into the suspect tissue.

3. Incisional biopsy is the removal of a small portion or wedge of tissue from a larger tumor mass. This type of biopsy is usually performed for larger tumors that will require major surgery for removal.

4. Excisional biopsy is the removal of the entire suspected tumor with little or no margin of surrounding normal tissue for diagnostic purposes. This is the most common surgical diagnostic procedure and is used for easily accessible tumors. For nonpalpable lesions, such as mammographic abnormalities of the breast, an excisional biopsy may be performed with the assistance of needle localization. Needle localization involves the placement of a radiopaque wire or needle into or near a nonpalpable radiographic abnormality to mark the site.

5. Exfoliative (surface) biopsy is the direct smear or scrape and examination of these shed cells as found in a Pap smear or brushings or washings from a bronchoscopy.

6. Invasive procedures may allow access to areas that are normally inaccessible. Upper endoscopy, colonoscopy, and laparoscopy are examples of procedures that provide access to areas for one or more types of biopsies.

B. Staging: Staging involves the pathologic examination of tissue to determine the size of the primary tumor, presence of positive lymph nodes, and extent of metastases. Surgical staging is most often performed for tumors otherwise inaccessible, or for those difficult to evaluate by any other means. Extensive surgical staging may be necessary before any major surgical procedure for cure. It provides a systematic approach to the diagnosis and treatment of malignancies.

1. Laparotomy: Exploratory operations may be performed to diagnose and stage cancers with intraperitoneal involvement (eg, laparotomy done to stage lymphoma). Second-look procedures may be performed after chemotherapy to evaluate ovarian cancer.

2. Laparoscopy: Laparoscopic surgery employs a laparoscope and video equipment to visualize internal structures with minimally invasive techniques. The laparoscope is placed into the peritoneum through a small incision. This is the main instrument for looking into the abdomen. Laparoscopic procedures may be used for diagnosis,
staging, and treatment of a variety of tumors involving the abdominal cavity, including esophageal cancer, gastric cancer, liver tumors, pancreatic cancer, adrenal tumors, and lymphoma. Biopsies or minimally invasive surgical procedures can be performed through additional small incisions using specially designed instruments. Laparoscopy is useful in evaluating metastatic spread of tumor before laparotomy. It is useful in determining the resectability of gastric cancer, pancreatic cancer, and hepatic tumors and may prevent laparotomy in cases of unresectable disease. Curative resections using laparoscopic techniques are being used in early lesions or for specific reasons.

3. Robot-assisted laparoscopy: Advances in technology have enhanced the use of robotics in surgery. Surgeons can perform complex surgeries by guiding and manipulating instruments by way of a computer and robotic arms. This minimally invasive laparoscopic technique is also used to prevent pain, decrease the amount of blood component administered, decrease length of hospital stay, and promote a more rapid recovery.

4. Sentinel node biopsy is used to stage a tumor such as melanoma. It is performed when the nodes appear clinically negative. An isotope is injected near a lesion or the site where the lesion was removed. A scan is performed to detect the spread of the isotope. A gamma probe is then used to locate the lymph node that picks up the most isotope, thus documenting the nodal drainage pattern for the area. If the tumor spreads, it will spread to the sentinel node first. This node is then excised. A full lymph node dissection is not performed unless the sentinel node contains cancer cells. This procedure is used in a number of cancer diagnoses and treatments.

5. Placement of radio-opaque clips during biopsy, staging and palliative procedures is important to mark areas of known tumor and as a guide to subsequent delivery of radiation therapy in the areas.

C. Treatment: Goals of treatment may include complete excision of malignant disease, control of cancer cell growth, or relief of symptoms associated with the cancer. The magnitude of surgical resection may be modified in the treatment of many cancers by the use of adjuvant therapies. Integrating surgery with other treatment modalities requires a careful consideration of all effective treatment options. The use of effective adjuvant treatment modalities has led to a decrease in the magnitude/extent of surgery in some instances.

1. Curative surgery or definitive surgical treatment for primary cancer involves the complete removal of the malignant tumor, primary lymph nodes, contiguous structures involved, and structures at high risk for tumor spread, along with a margin of normal tissue. The treatment of many solid tumors falls into this category. Usually, a metastatic evaluation for tumor spread will precede a surgical resection for cure. This is also important for staging. The goal of surgery is important in justifying the consequences. If function cannot be preserved, the potential for cure must be great. Resection of a primary solid tumor as the principal form of treatment includes lung cancer, colon cancer, breast cancer, and prostate cancer.

2. Salvage surgery is performed after the patient fails the first line of therapy and experiences recurrence as metastatic cancer from the primary cancer (eg, liver resection for metastatic colon cancer or neck dissection for a nodal metastasis from head and neck cancer).

3. Adjuvant surgery is aimed at removal of tissues to decrease the risk of cancer incidence, progression, or recurrence. It is also performed to reduce the size of a tumor as the extensive local spread of cancer may preclude the removal of all gross disease. This is referred to as cytoreductive surgery. Cytoreductive surgery is of benefit only when other treatments are available and may be effective in controlling residual disease that is unresectable.

4. Palliative surgery is performed to promote patient comfort and quality of life without curing the disease. The goal of palliative surgeries is to relieve symptoms of obstruction, pressure, and pain. Palliative surgery may relieve mechanical problems such as intestinal obstruction, or may be used for the removal of masses that are causing severe pain or disfigurement.

a. Interventional procedures for palliation of obstruction. The use of stents to maintain patency of a lumen has greatly aided in the control of symptoms and quality of life for patients with cancer. Stents may be made of synthetic material or metal. They can be placed either endoscopically by a gastroenterology endoscopist or percutaneously by an interventional radiologist. Stents may be placed endoscopically to relieve esophageal, duodenal, biliary, or colonic obstruction. Stents can also be placed percutaneously for biliary obstruction by interventional radiologists.

b. Palliative surgeries are also used to create diversions of normal function due to the presence of tumor. Placement of nephrostomy tubes or creation of a colostomy or ileal conduit are examples of surgery for this purpose.

5. Other surgical modalities used for ablation of tumor cells in the treatment of cancer

a. Cryosurgery uses liquid nitrogen to selectively freeze cancerous tissue, resulting in cell death. This modality is used mainly to treat gynecologic cancers and skin cancers.

b. Lasers may be used in certain procedures. Laser is an acronym for light amplification by stimulated emission of radiation. This treatment modality may be associated with less bleeding and scarring.

(1) In laser procedures, a laser is attached to a contact tip or scalpel to provide a focused form of energy to incise within a precise location and depth of tissue (eg, a laser cone of the cervix and the use of a laser during endoscopy to open obstructed lumens, particularly the esophagus).