Surgery for Cancer

What is cancer surgery?

As we all know, cancer leads to formation of large, rapidly growing tumours which obstruct function, impinge on healthy tissues, and also spread to distant cells through metastasis. Surgery is a mode of treatment, diagnosis, and palliative care for cancerous growths. The specialists who perform these procedures are called surgical oncologists.

What are the types of cancer surgery?

Depending on the key function of the surgery, there are many types of surgeries:

  • CURATIVE SURGERY: the main aim of surgery is to remove the tumour from the individual’s body. This is done in initial stages for well-defined tumours which haven’t spread to other organs. Surgery may be accompanied by chemotherapy or radiation therapy.
  • PREVENTIVE SURGERY: tumours or growths which have a tendency to turn cancerous are removed surgically as a preventive measure. For example, if a polyp which is not cancerous, appears pre-cancerous, it is removed surgically.
  • DIAGNOSTIC SURGERY: to confirm the occurrence of cancer, the oncologist needs to see the cellular changes in the tumour. Study and observation of a small part of the tissues for diagnosis is called biopsy. Biopsy can be of two types:

             Incision biopsy: a small portion of the tumour or suspected mass is excised and viewed under a microscope.

             Excision biopsy: the tumour is too big and the entire mass needs to be removed from which a small portion is examined under microscope.

  • STAGING: treatment of a cancer, widely depends on the stage of the cancer. Staging is done in order to figure out the size and extent of the spread of tumour. The oncologist may even take a sample of the associated lymph nodes to see if the cancer has spread. The samples are then biopsied.
  • DEBULKING SURGERY: in some cases, the spread of tumour may be so extensive that removal of the entire mass may cause more harm than good. In such cases, the surgeon removes a portion of the tumour. Other treatment modes like chemotherapy and radiation therapy may be used along with this.
  • PALLIATIVE SURGERY: this is a type of surgery in which the procedure does not cure the patient of cancer but reduces the discomfort and pain associated with it. It is usually done in widespread cancers which may be impinging in vital organs or the cancer which may cause bleeding.
  • RECONSTRUCTIVE SURGERY: once the primary surgery is done, the part of the patient may need surgical reconstruction to restore function, structure and aesthetics. One of the most common examples of reconstructive surgery is breast reconstructive surgery after mastectomy.
  • SUPPORTIVE SURGERY: these surgeries are again not curative but make the primary curative surgery easier. For example, catheter insertion for chemotherapy.

Apart from conventional surgical means, there are various recent developments to improve the success rate of the surgical procedure. Some of these are:

  • CRYOSURGERY: it is a type of surgical procedure which involves subjecting the cancer cells to extremely cold temperatures leading to freezing off of the cells. This procedure may be performed on the external surface or on the internal surface using a cryoprobe.
  • LASER SURGERY: LASER stands for light amplification by stimulated emission of radiation. Here, light energy is used to destroy cancer cells instead of mechanical surgery. It is a very precise technique which focuses on minute parts of the tumour like rectum, cervix, larynx, and skin.
  • ELECTROSURGERY: electrical energy is used to destroy the cancer cells. It is mainly used in skin cancers and oral cancers.

SURGICAL TREATMENT FOR VARIOUS CANCERS:

  1. PROSTATE CANCER SURGERY:

Prostate cancer surgery has two main types of approaches- radical surgery and laparoscopic surgery.

Radical prostatectomy: It is a traditional approach to prostatectomy where the complete gland is removed. There are two approaches to this procedure:

  • Radical retropubic prostatectomy: the initial incision is at the lower abdomen, up to the pubic bone. The surgeon may also sample some of the associated lymph nodes to check for the spread. If the spread of cancer has approached the lymph nodes, the surgeon will not proceed with the surgery as it may cause more harm than help.
  • Radical perineal approach: In this type of approach, the surgeon makes an incision from the skin between the anus and scrotum. This method is not used as commonly as it leads to erectile dysfunctions and does not allow access to the lymph nodes. These surgeries are relatively shorter and less painful.
  • Transurethral resection of the prostate (TURP): this is a palliative surgery to relieve symptoms. The surgeon uses an instrument called resectoscope and removes the inner part of the prostate gland.

Laparoscopic prostatectomy: Laparoscopy is a surgical approach which uses small incisions and long instruments. It is minimally invasive and leaves less scar tissue. The surgeon may use long instruments directly or through a control panel to control the instruments.

  • Laparoscopic radical prostatectomy(LRP): the surgeon inserts long instruments which can reach the prostate through small incisions. One of the instruments will have a camera at the end. This allows the doctor to see the path as he/she navigates through the body. This procedure has lower bleeding and shorter hospital stay. It may even be less painful than the traditional methods.
  • Robot-assisted laparoscopic radical prostatectomy: instead of manually manoeuvring the instruments, the surgeon controls the instruments from a control panel and robotic arms perform the surgery. This provides more dexterity and precision to the doctor.

SIDE EFFECTS OF SURGERY:

  • Urinary incontinence: the patient is unable to control passage of urine and may have a dribble or leakage of urine. There are various levels: stress incontinence, overflow incontinence, urge incontinence, continuous incontinence.
  • Erectile dysfunction: the penile erection in humans is controlled by two bundles of nerves. The surgeons usually try to avoid damaging these nerves or at least on bundle of nerves is left undisturbed (nerve-sparing surgery). if one bundle is damaged, the patient may not have spontaneous erections. It both are damaged; the patient may not have erections at all. This again depends on the surgeon and the age of the patient. Medications may be taken to aid return of function (sildenafil, alprostadil).
  • Changes in orgasm: patient may report a “dry” orgasm or reduced occurrence of orgasms. Rarely, the patient may also have painful orgasms.
  • Loss of fertility: the vas deferens, the duct which carries the sperms from the testicles to the urethra is ligated (cut). So, the sperms are produced but are not released. Patients who want to father a child may have to go for alternatives like sperm banking prior to the surgery.
  • Lymphedema: this may occur due to removal of many of the lymph nodes. The lymph fluid may accumulate in the patient’s limbs and genitals.
  • Inguinal hernia: a prostatectomy increases the chances of developing an inguinal hernia.
  • THYROID CANCER SURGERY:

Depending on the extensiveness of the tumour, there are various types of surgical procedures.

  • Lobectomy: it is a surgical procedure where the entire thyroid need not be removed. The surgeon makes an incision on the neck and resects the affected lobe, usually along with the isthmus. This surgery is performed in cases where the cancer does not show signs of spreading to other parts or also used as a diagnostic measure if FNAC is not clear. The main advantage of this type of surgery is that the patient may not need to take thyroid hormone supplements after surgery.
  • Total Thyroidectomy: this procedure involves complete removal of the thyroid gland. The procedure is similar to that of lobectomies. Sometimes, the surgeon may leave a small portion of the thyroid gland back. This is called near-total thyroidectomy. If some of the gland is left behind, it is called sub-total thyroidectomy. Once the surgery is performed, the patient will be put on thyroid supplement pills (levothyroxine) for his/her entire life. Recurrence can be detected with radioiodine scans and thyroglobulin blood tests.
  • Lymph node removal: if the lymph nodes are affected, the associated lymph nodes are also removed. This is done by a procedure called modified radicular neck dissection or central compartment neck dissection.

SIDE EFFECTS OF SURGERY:

  • Hoarseness of voice (may be temporary or permanent)
  • Parathyroid glands removed/damaged: this leads to low blood calcium levels, which causes muscle spasms, numbness and tingling sensations.
  • Hematomas (large blood clots)
  • LUNG CANCER SURGERY:

There are different types of lung surgery:

  • Lobectomy: the lung is divided into lobes. The left lung has two lobes whereas the right lung has three lobes. This surgery involves removal of one lobe when the cancerous tumour is limited to one lobe only.
  • Bilobectomy: this is a variation of the lobectomy where two lobes are removed.
  •  Pneumonectomy: the entire lung is removed in this type of surgery. the cancerous tumour is usually present either centrally or involving two or more lobes. The patient can manage to respire with just on lung.
  • Removing a section of the lung: when the tumour is in initial states, the surgeon can remove just one section of the lung. There are many types:
  • Wedge resection
  • Segmentectomy
  • Sleeve resection
  • Removal of lymph nodes.
  • SURGERY FOR BREAST CANCER:

The different types of surgery for breast cancer are:

  • Lumpectomy or partial mastectomy: it is a breast conserving surgery. When only a part of the breast is involved, that portion of the breast is removed.
  • Mastectomy: this procedure involves removal of the entire breast and also some amount of normal tissues to prevent recurrence.
  • Removal of affected lymph nodes: axillary lymph node is the associated lymph node. It is present at the armpit region. It is removed if the scans show that the cancer has spread outside the milk duct.

Sentinel lymph node removal is a procedure where only the directly affected lymph nodes from under the arm are removed.

Axillary lymph node dissection is when many lymph nodes (less than 20) are removed from under the arm.

  • Breast reconstruction surgery: it is the re-building of the breasts after mastectomy or lumpectomy. It is done to restore anatomic form and structure for aesthetics. It may even be done as soon as the primary surgery is completed. Some women may prefer prosthesis instead.
  • Prophylactic ovary removal: it is believed that oestrogen feeds the breast cancer. Removal of the source for oestrogen will reduce the rate of growth of the tumour.
  • Prophylactic mastectomy: sometimes, mastectomy is performed even when the patient is not diagnosed of breast cancer but has a potential to develop cancer.  
  • SURGERY FOR LIVER CANCER:

Surgery for primary liver cancer is done only if the cancer has not spread widely as this allows the best chance for recovery. The different types of surgery for liver cancer are:

  • Lobectomy: when only one lobe is affected, the surgery is performed to remove the affected lobe specifically. This is also known as hemi hepatectomy. The liver has a capacity to grow back the missing portion in due time. The surgery is not performed if the patient has any underlying liver disorders like liver cirrhosis.
  • Liver resection: the affected portion, along with the surrounding normal tissue is removed. It is done only when the tumour is small and well-circumscribed.
  • Liver transplant: when the conditions are not suitable to support lobectomy, liver transplant is carried out. For liver transplant, the patient needs to:
  • Have no more than 5 small tumours, each of which are 3cm or less.
  • Or have a single tumour which is 5cm or less, across
  • Or have a single tumour which is 5-7cm across but has not grown in the past 6 months.

Liver transplant is done in cases of hepatocellular liver cancer.

Surgery for Cancer Treatment in India

If the tumours are bigger in a primary liver cancer, radio-ablation or chemotherapy is used to shrink the tumour and then the surgery is performed.

The patient is put on immunosuppressants continuously after a transplant. These medications have their own set of risks like reduced immunity, increased risk of high cholesterol, blood pressure and diabetes.

  • SURGERY FOR CANCER OF THE KIDNEY:

Almost all cancers of the kidney are invariably treated with surgery. Surgery aids better recovery and health even if the cancer has spread to other parts. Surgical treatments for cancer of the kidney includes:

  • Radical nephrectomy: in this surgery, the oncologist removes the affected kidney, associated adrenal gland (which is present over the kidney), fatty tissues surrounding the kidney. The surgeon begins by making an incision vertically either in the front, below the ribs, or behind the kidney. In some cases, the surgeon may leave behind the adrenal gland if the tumour is close to the lower portion of the kidney.

In recent developments, the entire procedure is carried out using laparoscopy. Minute incisions are made and long handled instruments are used to remove the kidney. The incisions are about 1.27cm long

The laparoscopic surgery may either be performed manually or using robotic control.

  • Partial nephrectomy: it is also known as nephron sparing surgery. In this procedure, the surgeon removes only the part of the kidney which is affected by the tumour. It is the choice of treatment for cancers that are in early stage and/or less than 4cm in size. This again, may be performed through laparoscopy.
  • Regional lymph node dissection: the associated lymph nodes are removed if the surgeon feels that the cancer has metastasized to other parts, and if the lymph nodes are appearing abnormal.
  •  Adrenalectomy: this procedure is usually carried out with the primary surgery and is dependent on the spread of cancer.
  • SURGERY FOR COLORECTAL CANCER:

Surgery is the primary mode of treatment for colorectal cancers. The type of surgery depends on the extent of the spread of cancer. Radiotherapy and chemotherapy may be given as an adjunct with the surgery. The types of surgeries available are:

  • Polypectomy: this type of surgery is one of the most basic surgeries. The cancerous portions are removed as polyps, at the stalk, using an electric arc. This procedure can also be done during colonoscopy.
  • Local excision: special tools are used to remove the cancerous portions during a colonoscopy.
  • Hemicolectomy: this procedure involves surgical removal of a part of the colon. Usually one-fourth to one-third of the colon is removed.
  • Total colectomy: this procedure involves complete removal of the colon. This is done in extensive cases of cancer. It is usually done only when there are additional problems in the colon which cannot be treated by other procedures.
  • Colostomy and ileostomy: this is done when the colon is blocked by the tumour. A stent is placed to relieve the block prior to the surgery. Then, it is followed by a procedure similar to colectomy but instead of reconnecting the ends of the colon, the upper end is attached to an opening on the skin, called stoma.
  • Lymph node dissection: the affected lymph nodes are removed along with the primary surgery.

These surgeries can be performed either as open incision surgeries or as laparoscopic surgeries.

  • SURGERY FOR BRAIN CANCER:

Surgery is the first line of treatment for brain cancer. The process is initiated with biopsy, along with which the entire tumour may be removed. The size of the tumour is reduced to relieve pain, restore function, and to relieve seizures. The types of surgeries available are:

  • Craniotomy: procedure which involves removal of a portion of the skull to locate and access the tumour. The portion of the skull that was removed is replaced after surgery.
  • Craniectomy: a procedure which is very similar to craniotomy but the only difference is that the removed part is not replaced after surgery.
  • Partial and complete removal of tumour: depending on the extent of the tumour, either partial removal or complete removal is done. Complete removal has higher risks of neurological complications.

Risks involved in brain surgery:

  • Seizures
  • Weakness
  • Balance/coordination difficulties
  • Memory or cognitive problems
  • Spinal fluid leakage
  • Meningitis
  • Brain swelling
  • Stroke
  • Excess fluid in the brain
  • Coma
  • Death
  • SURGERY FOR OVARIAN CANCER:

Surgery is the primary mode of treatment for ovarian cancer. The accurate staging of cancer is of utmost importance as it determines the extent of surgery and child-bearing ability of the affected woman. The common surgical procedures available are:

  • Hysterectomy: the complete uterus is removed and is sent for biopsy to determine the stage.
  • Bilateral salphingo-oophorectomy(BSO): the removal of both the ovaries and the fallopian tubes.
  • Omentectomy: removal of the omentum (fold of peritoneum connecting the stomach with other abdominal organs)
  • Lymph node dissection: lymph nodes of the abdomen and pelvis. 

 Debulking of the tumour is a procedure in which the size of the tumour is reduced with surgery and the treatment is continued with either chemotherapy or radiation therapy. Optimal debulking is a process where the tumour size is not more than 1cm.

  1. SURGERY FOR BONE CANCER:

Bone cancers are treated primarily with surgery and adjuncts of other treatments may be used along with it.

Some of the common surgeries for bone cancer are:

Surgeries for the limbs:

  • Limb-salvage surgery: the part of the bone that is affected by the cancer is removed surgically. The structure and function is restored using grafts or endo-prosthesis. The prognosis for this type of surgery is very good. The function of the limb is restored only with the patient’s physiotherapy.
  • Amputation: the entire bone or limb which is affected is removed. The amputated limb is then replaced with prosthesis. This type of extensive surgery is reserved for cancers which have spread to the nerves, arteries and muscles and the removal of the entire limb is essential.
  • Reconstructive surgery: surgical techniques used to rebuild the amputated part.

               Surgeries for other regions:

  • Wide excision
  • Curettage
  • Cryosurgery

COST OF SURGERY:

The cost of surgery varies widely on the technique, combination of surgeries, the extent, and the location and difficulty of the surgery. Approximately, the range of cost for surgery is $3000-$10000.