Curative surgical resection

Oxford American handbook of oncology. Second Edition. Oxford University Press (2015)

The long-term outcome after cancer surgery depends on tumor type and the stage of tumor at presentation.

  • For some cancers, the outlook is favorable for the majority of patients. The five-year survival rate in breast cancer is over 80% and for colon cancer it is approximately 70%. Unfortunately, the cure rate for many tumors is much lower. The five-year survival rate for lung cancer is approximately .5%, and for pancreatic and esophageal cancer the five-year survival is less than 10%.
  • Survival rates for some cancers have improved due to earlier presentation, improved public awareness, and screening programs (such as with breast and cervical cancer). Screening for colon cancer has also been successful, but screening is still under investigation for lung cancer.
  • Improvement in surgical and anesthetic techniques has enabled the performance of extensive resections, with low risk (when performed by specialists) and excellent functional results, such as limb-preserving surgery for osteosarcoma, esophagogastrectomy, and pancreatectomy.

The concept of multidisciplinary evaluation and management of patients with cancer is extremely important

  • Surgical resection may have an important role in the management of most solid tumors; however, pretreatment evaluation by medical oncologists or radiation oncologists may be necessary to optimize treatment planning.
  • The use of either induction therapy (preoperative) or adjuvant therapy (postoperative) is well established for most tumor types, although the relative efficacy of each may evolve over time as new agents are developed and clinical trials are completed. For example, for patients with lung cancer, adjuvant chemotherapy has been shown to improve outcomes for patient with stage II disease, yet induction therapy is preferred for patients with stage IIIA disease.
  • Similarly, preoperative chemotherapy may be used for locally advanced breast cancer, although most women will receive adjuvant chemotherapy only.

The tenets of complete surgical resection when possible are important for virtually every solid tumor

  • R0 resection refers to complete resection of all tumor. R1 resection refers to resection of gross tumor, with microscopic disease remaining. R2 resection denotes gross tumor unresected.
  • The terminology for complete resection is important, but tumor margin may vary by tumor type, and close cooperation between the surgeon and the pathologist is essential. For example, wide local excision for breast cancer requires a margin of between 0.5 and 1 cm, whereas in colorectal cancer surgery a 5 cm margin proximally and a 2 cm margin distally should be achieved.
  • The outcomes of many oncologic surgical procedures are superior in centers with higher volumes and when performed by surgeons with more experience, including pneumonectomy, esophagectomy, and pancreatectomy.
  • Although colectomy is considered a relatively standard procedure, resection for rectal cancer is more complicated. Total mesorectal excision is essential to prevent local recurrence in the pelvis after rectal cancer, and this specialized technique is best done by surgeons who perform a considerable number of these procedures.

The use of MIS and robotic techniques in the definitive treatment of malignancy is evolving

  • Currently, thoracoscopic lobectomy for lung cancer is an accepted option with numerous advantages, as is laparoscopic resection for colon cancer.
  • Minimally invasive and robotic approaches to surgery of the kidney, thymus, esophagus, adrenal, and prostate are also performed.
  • Through a collaborative process, the American Society of Clinical Oncology (ASCO), the NCCN, and the Commission on Cancer (CoC) have agreed on various quality measures in treatment of patients with breast cancer, colon cancer, and rectal cancer that surgeons should use. For example, at least .2 regional lymph nodes should be removed and pathologically examined for resected colon cancer.

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