Combating Malignancy
Medical experts emphasise the importance of accurate diagnosis, multidisciplinary collaboration, and patient-centred treatment plans in navigating the complexities of cancer surgery…
By Team Double Helical
Cancer surgery is a highly specialised branch. A doctor who specialises in surgical treatment of cancer is called a surgical oncologist. Surgery is the oldest type of cancer therapy and remains an effective treatment for many types of cancer today.
Considered the most effective among available cancer treatment options, minimally invasive surgery is increasingly sought after. However, it is a highly specialised technique that also requires extensive training, a multidisciplinary team, and strong paramedical support.
According to Dr A K Singh, Senior Neurologist associated with MAX Hospitals in Dehradun, cancer is a diverse group of several hundred entities that can originate from virtually any part of the body. It occurs when normal cells undergo changes and begin to proliferate uncontrollably. These abnormal cells can aggregate to form a mass known as a tumor. Tumors can be either malignant, meaning they have the potential to spread to other parts of the body, or benign, indicating they are noncancerous. However, certain types of cancer do not produce solid tumors; these are referred to as hematological malignancies. Examples include leukemia, various forms of lymphoma, and myeloma, which affects the plasma cells in the bone marrow, the soft tissue inside bones
Types of Surgery
Diagnostic: For most cancers, a biopsy is the only way to make a definitive diagnosis. A biopsy is the removal of a small amount of tissue for further study. During a surgical biopsy, the surgeon makes an incision in the skin and removes a portion or all of the suspicious tissue. There are two primary types of surgical biopsies: incisional, which involves removing a piece of the suspicious area for examination, and excisional, which entails removing the entire suspicious area, such as an abnormal mole or lump.
Following the biopsy, the removed tissue undergoes microscopic examination by a pathologist, a doctor specialising in interpreting laboratory tests and assessing cells, tissues, and organs to diagnose diseases. The pathologist provides a pathology report to the surgeon or oncologist, who then establishes the diagnosis.
Staging: Staging surgery aims to determine the size of the tumour and whether it has spread, often involving the removal of nearby lymph nodes, small bean-shaped organs aiding in infection fighting, to assess potential spread. Combined with physical examinations, biopsies, laboratory tests, and imaging results, staging surgery assists doctors in determining the optimal treatment and predicting the patient’s prognosis, or likelihood of recovery.
Tumour Removal (Curative or Primary Surgery): The most common cancer surgery involves removing the tumour along with some surrounding tissue, known as the margin. Tumour removal may serve as standalone treatment or be combined with chemotherapy, radiation therapy, or other modalities, administered before or after surgery.
Conventional surgery involves large incisions through the skin, muscle, and sometimes bone. However, in select cases, surgeons may opt for less invasive techniques to expedite recovery and minimise postoperative pain.
Debulking: When complete tumour removal poses risks of excessive damage, surgeons perform debulking surgery to remove as much of the tumour as feasible. Additional treatments like radiation therapy or chemotherapy may be employed to shrink the remaining cancer.
Palliation: Palliative surgery aims to alleviate side effects induced by tumours, enhancing the quality of life for patients with advanced or widespread cancer. It can relieve pain or restore physical function by addressing issues such as nerve compression, spinal cord compression, bowel obstruction, or bleeding. Dr Arun Sharma, Senior Neurosurgeon at the Indian Spinal Injuries Centre in New Delhi, notes that certain cancers, occurring in vascular-rich areas like the uterus or in fragile organs such as the esophagus, stomach, and bowel, are more prone to bleeding and may benefit from surgical intervention to control bleeding.
Additionally, bleeding may result from certain medications used in cancer treatment. When surgery becomes necessary to control bleeding, a common technique is suture ligation, which involves tying off blood vessels using surgical thread. Surgery may also involve the insertion of feeding tubes or medication delivery tubes. If cancer or its treatment impedes eating, a feeding tube may be inserted directly into the stomach or intestine through the abdominal wall, or a tube may be placed into a vein to administer pain medication or chemotherapy. Surgery may also be employed to prevent fractures in bones weakened by cancer or its treatment; inserting a metal rod can help prevent fractures and alleviate pain during healing.
Reconstruction: Following primary cancer surgery, reconstructive or plastic surgery may be performed to restore the body’s appearance or function. This can occur concurrently with tumour removal surgery or after the patient has healed or undergone additional treatment. Examples include breast reconstruction post-mastectomy and surgery to restore appearance and function following head and neck surgery.
Prevention: Some surgeries aim to mitigate the risk of developing cancer. For instance, doctors may recommend the removal of precancerous polyps in the colon to prevent colon cancer. Additionally, women with a strong family history of breast or ovarian cancers or known mutations in the BRCA1 and BRCA2 genes may opt for mastectomy or oophorectomy to reduce the risk of developing these cancers.
Types of Minimally Invasive Surgery
While conventional surgery often necessitates large incisions, minimally invasive procedures involve one or more small incisions, leading to shorter recovery times and reduced postoperative pain. Examples include:
Laparoscopic Surgery: The doctor performs surgery through small incisions in the skin using a thin, lighted tube with a camera. For example, a laparoscopy refers to a minimally invasive surgery of the abdomen, and mediastinoscopy and thoracoscopy are terms used when the same type of procedure is performed in the chest.
Laser surgery: The doctor uses a narrow beam of high-intensity light to remove cancerous tissue.
Cryosurgery: The doctor uses liquid nitrogen to freeze and kill abnormal cells. Mohs micrographic surgery also called microscopically controlled surgery: The dermatologist shaves off a skin cancer, one layer at a time, until all cells in a layer appear to be normal cells when viewed under a microscope.
Robotic Surgery: This is the latest in minimally invasive techniques of cancer surgery in which the operating surgeon uses a robotic system to perform the surgery. The surgeon is sitting comfortably on the console at some distance while the robot is performing the operation based on the instructions of the surgeon. This system has several advantages like better magnification, degrees of movement, 3D vision and faster rehabilitation. However, the steep cost is the limiting factor.
Endoscopy: The doctor inserts a thin, flexible tube with a light and camera on the tip, called an endoscope, into an opening of the body (such as the mouth, rectum, or vagina) to examine the internal organs. During an endoscopic procedure, it is possible to remove samples of potentially abnormal tissue for further examination.
Dr A K Singh said, “The goals of surgery vary. It is often used to remove all or some of the cancerous tissue after diagnosis. However, it can also be used to diagnose cancer, find out where the cancer is located, whether it has spread, and whether it is affecting the functions of other organs in the body. In addition, surgery can be helpful to restore the body’s appearance or function or to relieve side effects”.
The location where you have surgery depends on the extent of the surgery and how much recovery is needed. Surgery may be performed in a doctor’s office, clinic, surgical centre, or hospital. Outpatient surgery means that you do not need to stay overnight in the hospital before or after surgery. Inpatient surgery means that you do need to stay in the hospital overnight or longer to recover after the surgery.
Dr Arun Sharma, added, “The diagnosis of cancer begins when a person reports any unusual symptoms. After discussing a person’s medical history and his or her symptoms, the doctor will perform various tests to find out the cause of the ailment. However, many times a person with cancer has no symptoms. Sometimes a doctor diagnoses cancer after a cancer screening test in an otherwise healthy person. Examples of screening tests include a colonoscopy, a mammogram, and a pap test.”
The results of these tests may necessitate additional tests to confirm or disprove the result of the screening test. Less often, cancer is diagnosed when a person undergoes a medical test for another reason. The cancer treatment options that the doctor recommends depends on the type and stage of cancer, possible side effects, and the patient’s preferences and overall health. In cancer care, different doctors often work together to create a patient’s overall treatment plan that combines different types of treatment. This is called a multidisciplinary team approach.