1. BIOPSY: 1. Palpable nodules - needle aspiration cytology or needle core biopsy
2. Occult lesions - ultrasound guided or mammographic stereotatic biopsy
Note that an open surgical biopsy for the purposes of making the diagnosis of the breast lesion is rarely required and neddle biopsy can achieve the same purpose. With the diagnosis in hand then the open surgical resection can be planned. Occasionaly the lumpectomy and diagnosis can be combined in the same procedure, however the frozen section diagnosis will require nearly 30 minutes during the procedure. Immediate diagnosis in not necessary when the outcome will not change the procedure, i.e., lumpectomy with widely clear margins and sentinel node procedure is defered.
2. LUMPECTOMY, SEGMENTECTOMY AND QUADRANTECTOMY:
Lumpectomy is removing a sphere of breast tissue with the tumor centered in the sphere and 1 cm margins would be ideal. Segmentectomy removes a lobe, shaped like an orange segment, from the breast which encompasses the tumor and the draining duct system. Segmentectomy will remove in addition to the presenting tumor, other not so obvious small tumors along the duct, i.e. multifocal disease. Quadrantectomy usually encompass 2 or 3 segments and is reserved for large tumors or tumors at the edge or periphery of the ductal system. The primary goal of the surgical resection of tumor is to obtain clear margins and effect maximal local control which can be translated into low local recurrence rates. The secondary goal is to obtain optimal cosmetic results which can be achieved even with larger resections such as segmentectomy and quadrantectomy. Alreolarplasty is often performed with the breast closure, by aposing adjacent breast tissue into the retroareolar space and projecting the nipple with purse string type suturing.
2.1 MINIMALLY INVASIVE LUMPECTOMY
Small cancers are ideal for lumpectomy or segmentectomy procedure. Usually additional sites of tumors are located along the ductal system of the primary tumors, consequently a segmentectomy can encompass these additional multifocal tumors. Cosmesis can be achieved without compromising the extent of lumpectomy or segementectomy to obtain optimal curative results. The incision and access to the lumpectomy cavity can be limited to a 3-4 cm length on the skin and likewise in the subcutaneous and breast tissue using a cylinder retractor designed by Dr Chu (US patent # 5,882,316). Once the tumor segment is reached then a wider resection and cavity is developed. The cavity after closure of the breast, heals by first filling up with tissue fluid then conversion or laying down of scar tissue. Usually the volume and conformity of the breast is preserved unless the fluid is drained out due to infection or collapse of breast tissue.
2.2 SUB-AREOLAR TUMORS
Tumors close to the nipple are associated with occult in-situ cancers in the main ducts of the nipple. Some primary tumors of the main ducts, Paget's disease, may not be associated with other invasive tumors in the breast parenchyma. The nipple can be spared as long as all tumor is removed with clear margin. Even if part of nipple remains, the nipple can be reconstructed with good results. Preoperative evaluation can also employ ductoscopy and ductogram. Resection of tumors near the nipple can remove tissue in the nipple and behind the areola. The post operative appearance of the breast is quite satisfactory. Breast tissue need to be approximated under the nipple to avoid nipple retraction.
3. SENTINEL NODE (SLN) MAPPING
The lymphatic drainage of the breast is predominantly to the axillary nodes. Central and medial cancers can drain to nodes along the breast bone, the sternum, called the internal mammary nodes, and the majority will at the same time drain into the axillary nodes. Nodes just above the clavicle (supraclavicular nodes) can also be involved although a rarity without axillary node involvement. In addition, the sentinel node(s) is found mainly in the central group of axillary nodes, see illustration. A 2-3 cm transverse incision is made in the low axilla and once the deep subcutaneous scarpa's facia is entered. The blue dye or radioactivity inbedded in sulfa-colloid particles can be detected by visual inspection and by using the gamma probe, respectively. In addition, the sentinel node can often, be palpable, making the identification easier, using the surgeon's finger. The palpable sentinel node has been called the dominant node. The hypertrophy of the sentinel node contribute to its palpability and reflects functionality of the local cellular responses in the lymph node due to the tumor or reaction to previous biopsy. The American College of Surgeons Oncology Group and the National Surgical Breast and Bowel Project have studies which will shed more light on the need of added node dissection for micrometastases, involved nodes, etc. We should be reminded that if the lymph nodes are clinically positive, node dissection should be carried out. The SLN Working Group led by Drs Stanley Leong at the University of California, San Francisco and Harold Wanebo of Brown University, is also involved in studying clinical questions of lymph node metastasis in breast cancer and melanoma.
II. COLON AND RECTUM
1. TRANS-ANAL ENDOSCOPIC TECHNIQUES
Colonoscopy, sigmoidoscopy or anoscopy can be used to remove polyps in the large bowel and rectum. Pre-malignant polyps and cancers that invade the inner layer of the bowel only can be safely removed endoscopically. More advanced rectal tumors may be candidates for trans-anal resection if the response to chemoradiation is nearly complete. Otherwise local excision only may result in high recurrence rates.
2. MINIMALLY INVASIVE RESECTION
Clearly, in some patients, minimally invasive techniques can lead to more rapid healing, and lesser pain in the post-operative period. The techniques are still in evolution. The tumor can be removed through a smaller incision combining the use of the surgical hand, intra-abdominal camera view magnification, and laparoscopic instruments. The procedure can begin with small incisions and dissection done by instruments inserted through the access ports, then the tumor can be delivered out of the abdomen through a larger incision and bowel re-connection performed outside the abdomen. The anastomosis, sewing the bowel back together, can also done inside the abdomen, without a large incision for exposure. From a cancer control standpoint we cannot yet endorse using laparoscopic techniques for T3 and T4 tumors due to the potential for tumor cell spillage and higher rates for local and regional recurrence.
It is easy to be persuaded by someone who shows the result of small scars and swift recovery and conclude that minimally invasive surgery is superior to other operations requiring a larger incision. The result that really counts is the cure and disease free rates. Admittedly, these results are harder to measure and not available at this time. The best option is to consult a seasoned surgical oncologist who has a track record in obtaining high cure rates and who can also employ the techniques of minimally invasive surgery. One must also consider the options of chemo and biological therapy with or without radiation to minimize the risk of recurrent disease.
Primary and secondary liver tumors are known to be bad actors. The prognosis is more promising for resectable liver tumors. Since there is a wide range of biological behavior depending on the origin of the liver tumors, we will limit our discussion to the two most common types, the metastatic tumors from colorectal cancer and the primary hepatoma tumors also known as hepatocellular carcinoma. Both liver tumors will be helped by systemic chemotherapy, regional artery or vein based infusions. These regimens can be given prior to or after surgery.
1. WEDGE OR ANATOMICAL SEGMENT/LOBAR RESECTIONS
The main impediments for a successful resection of the liver and speedy recovery are the blood loss and liver reserve. The liver is highly vascular, having a dual blood supply, consisting of the arterial and portal systems. Liver fractures from trauma and incisions from stab wounds are known to esanguinate if not controlled. Liver cirrhosis even to a mild degree can lead to liver decompensation if accompanied by high blood loss or long interruption of blood supply during the procedure. The use of liver clamps can lessen blood loss and decrease the time of blood flow interruption to the parts of liver not resected. Dr Chu has designed a novel liver clamp (Pilling 604113-61995) that achieves these goals which in the end shortens operative time, decreases blood loss, shortens hospital stay and allows resection on multiple lesions. The resection with judicious application of the liver clamp can also expand the indications for liver resection in older individuals and in patients with more severe cirrhosis.
Laparoscopic techniques to resect peripheral liver tumors are under development.
2. LIVER ABLATIVE TECHNIQUES
Liver tumors that are deemed unresectable can be ablated by radiofrequency cauterization delivered through special designed metal needles or by cryotherapy achieved by low temperatures extracted by special liver trochars. The local recurrence rate is higher than that of resection. The margins of the treatment field, near main vessels, or near surrounding organs are limitation of this ablative technique, since complications to adjacent structures can ensue. The healing process is also called into question since there is a large quantity of necrotic tumor for the body to resorb.
IV. PALLIATIVE PROCEDURES
Cancer surgery optimal results are measured by curability overall and by lack of local and regional recurrences, functionality and quality of life. Some radical procedures can be justified by the results in their ability to cure the patients, though some organs and functionality are sacrificed. In addition, many radical procedures can be modified, in order to accomodate functionality and quality of life, as the effectiveness of drugs and radiation have improved, without significantly sacrificing the cure rates.
The balance of risk and benefits of surgery become altered and examined in a different context when surgical cure is no longer possible or when the possibility of surgical cure is realistically low. This is the situation where palliative surgery is considered and weighed against other methods to improve quality of life. A multidisciplinary approach is paramount. The morbidity and mortality of the procedures can be higher due the complexity of the illness, however, when carefully considered, the complication rates have been comparable to operations in patients with curative potential.
Examples of effective palliative procedures:
1. Laparotomy for malignant bowel obstruction. Only a few cases are done for curative intent and palliation is usually the primary goal, including returning to eating regular food, avoiding abdominal destention and pain. Careful consideration for tumor resection, bowel resection, bowel bypass, tube decompression and diverting ostomy can optimized palliation.
2. Cytoreduction or debulking surgery for abdominal carcinomatosis. Most surgeons would include pseudomyxoma peritoneii or myxomatous carcinomatosis within the category of malignant carcinomatosis. Since the clinical and pathological spectra of these diseases vary widely in origin (appendix, mullerian rests, peritoneum, colorectal and ovaryan cancer), in matrix component (mucinous and solid tumor/fibrous reaction) and in growth rates, the treatment effectivess can vary from curative or excellent palliation to poor palliative results. Several recent publication of aggressive surgery combined with intraperitoneal chemotherapy have demonstrated good results. Intraperitoneal hyperthermic chemotherapy has also been advocated.
3. Metastasectomy. Resection of isolated tumor spread to skin, lung, liver, brain, abdominal cavity (see above IV - 1,2) can result in prolonged disease free interval. The magnitude of the surgical procedure associated with higher morbidity rates and longer recovery time need to be balance to the potential benefits and prolongation of good quality of life.
MULTIDISCIPLINARY APPROACH TO PALLIATION
The basic concept of bringing together multiple expertise for the care of complex disease processes of advance cancers is no-brainer. Besides hospice, psychosocial, rehabilitation components of the team, the interaction of drug, radiation and surgical therapies need further clarification. Undoubtedly there have been improvements in the agents, dosing, and delivery of therapy. In surgery, specifically, the targeted rather than the radical procedure may get better long term results. The principle of resecting wide margins and sacrificing "uninvolved" tissues, may no longer be valid in today's treatment armamentarium. Targeted surgical excision of tumor with minimally invasive approaches, that returns the patient to prefered quality of life. And in turn, the patient will be capable of receiving additional drug and/or radiation therapy without delay, will most likely achieve a more durable remission of disease.