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Treatment Modalities: Surgery
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Treatment Modalities: Surgery
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Professional Oncology Education
Treatment Modalities: Surgery
Time: 22:19
Barry Feig, M.D.
Professor
Surgical Oncology
The University of Texas, MD Anderson Cancer Center
My name is Barry Feig. I am a Professor of Surgical
Oncology at The University of Texas MD Anderson Cancer
Center in Houston, Texas. I am going to talk to you today
about the role for surgery in the treatment of patients with
oncologic diseases.
Spanish Translation
Modalidades de tratamiento: Cirugía
Transcripción del video
Educación Oncológica Profesional
Modalidades de tratamiento: Cirugía
Duración: 22:19
Dr. Barry Feig
Profesor
Oncología Quirúrgica
Universidad de Texas, MD Anderson Cancer Center
Mi nombre es Barry Feig y soy Profesor de Cirugía
Oncológica en el MD Anderson Cancer Center de la
Universidad de Texas, en Houston, Texas. Hoy voy a hablar
de la función de la cirugía en el tratamiento de pacientes
con enfermedades oncológicas.
Treatment Modalities:
Surgery
Barry Feig, M.D.
Professor
Surgical Oncology
1
Treatment Modalities: Surgery
Objectives
• Upon completion of this lesson, participants will
be able to:
– Discuss the roles of surgery for solid tumors and
hematologic malignancies
The objectives of this session [are] to be able to discuss the
role for surgery for both solid tumors and hematologic
malignancies; to describe the various biopsy techniques,
which are used including incisional biopsy, excisional
biopsy, open biopsy, core biopsy as well as fine needle
aspiration; and to discuss the complications of surgical
intervention as well as the role for surgery in palliation and
in patients with metastatic disease.
Los objetivos de esta sesión son analizar la función de la
cirugía, tanto en tumores sólidos como en hemopatías
malignas; describir las diferentes técnicas de biopsia que se
utilizan, como la biopsia por incisión, biopsia por escisión,
biopsia abierta, biopsia con aguja gruesa y aspiración con
aguja fina; y referirnos a las complicaciones de la
intervención quirúrgica, así como a la función de la cirugía
en la paliación y en pacientes con enfermedad metastásica.
So, traditionally surgery is the main modality for treatment
of patients with solid tumors. It can be used both as a
diagnostic means, a curative means and a palliative means,
and we will discuss all those individually.
For
hematological malignancies, surgery is not traditionally a
curative modality. It is more of a supportive modality.
Surgery is used for venous access, not infrequently for
decreasing the burden of disease by doing splenectomies in
patients with leukemia or lymphoma, as well as doing
biopsies in order to obtain diagnoses for patients with these
disease processes.
Tradicionalmente, la cirugía ha sido la principal modalidad
para tratar a pacientes con tumores sólidos. Puede utilizarse
como medio de diagnóstico y también como medio curativo
y paliativo, y nos referiremos a ellos individualmente. En el
caso de las hemopatías malignas, la cirugía no es una
modalidad curativa tradicional, sino más bien una
modalidad de apoyo. La cirugía se utiliza para el acceso
venoso, a menudo para disminuir la carga de la enfermedad
mediante esplenectomías en pacientes con leucemia o
linfoma, así como en las biopsias de diagnóstico en
pacientes con estos procesos.
– Describe various biopsy techniques including
incisional, excisional, open and core as well as fine
needle aspiration
– Discuss the complications of surgery for palliation or
in metastatic disease
Treatment Modalities: Surgery
Role of Surgery
• Solid Tumors
– Diagnostic
– Curative
– Palliative
• Hematologic Malignancies
– Supportive
• Venous access
• Splenectomy
• Biopsy for diagnosis
2
Treatment Modalities: Surgery
Role of Surgery
• Diagnostic
– Biopsy
So, from a diagnostic standpoint, traditionally surgical
biopsy was done by either incisional or excisional biopsy.
Nowadays, open biopsies like incisional or excisional
biopsy are much less common. We much more commonly
use fine needle aspiration or FNA, core biopsies, or imageguided needle biopsies.
A los fines del diagnóstico, la biopsia quirúrgica solía
hacerse con biopsias por incisión o escisión. En la
actualidad, este tipo de biopsias abiertas son bastante menos
comunes y son mucho más frecuentes la aspiración con
aguja fina, o FNA, y las biopsias con aguja gruesa o con
aguja guiada por imágenes.
Surgery has also traditionally been an important part of
staging the patient. Laparoscopic staging was initially a --was an initial use of laparoscopy in patients with cancer,
most commonly in patients with gastric cancer or pancreatic
cancer. However, as imaging modalities like CT scan, PET
scan, and MRI have markedly improved over the last
several years the use for --- the need for surgery in staging
has decreased. And it is fairly uncommon that we do
staging even using laparoscopic methods in patients with
cancer nowadays.
La cirugía también ha sido tradicionalmente una parte
importante de la estadificación del paciente.
La estadificación laparoscópica fue, inicialmente, uno de
los primeros usos de la laparoscopia en pacientes con
cáncer, con mayor frecuencia en aquellos con cáncer
gástrico o de páncreas; sin embargo, las modalidades de
estudio por imágenes como la tomografía computada, PET
y resonancia magnética han mejorado notablemente en los
últimos años, y la necesidad de cirugía para estadificación
se ha reducido y hoy es poco frecuente que la hagamos en
pacientes con cáncer, aun por métodos laparoscópicos.
• Incisional
• Excisional
• Open biopsy much less common
– FNA
– Core biopsy
– Image guided needle biopsy
Treatment Modalities: Surgery
Role of Surgery
• Staging
- Laparoscopic evaluation
• Most commonly in patients with gastric cancer,
pancreatic cancer
• Less commonly used due to the accuracy of
current imaging modalities
3
Treatment Modalities: Surgery
Role of Surgery
• Curative Treatment
• Surgery remains the only treatment modality
independently able to provide cure for most
solid tumors
• Principles
– Removal of all gross, visible tumor
– Surrounding margin (2cm) of normal tissue
– May require adjacent organ resection to achieve
adequate margin
Treatment Modalities: Surgery
Role of Surgery: Margin Assessment
• Adequate margin is used to insure all macroscopic
and microscopic tumor is removed
• Role for intra-op assessment may depend on the
disease site/tumor location
– Not helpful if there is no more tissue to take
or additional tissue would cause significant
morbidity/mortality
So, again the main purpose for surgery in patients with
solid tumors is curative treatment. Most patients --- even
patients understand that the best way to cure a tumor is to
take it out. It is the only treatment modality that
independently is able to provide cure for a large variety of
solid tumors. The basic principles of surgical resection for
cancer include the removal of all of the gross visible tumor.
And this should be done with surrounding margin of normal
tissue with a general rule of 2 cm being the accepted or the
ideal amount of normal tissue around the tumor that we
would like. In order to get that normal tissue around the
tumor, it may require resection of adjacent organs.
El propósito principal de la cirugía en pacientes con
tumores sólidos es el tratamiento curativo. Los pacientes
comprenden que la mejor manera de curar un tumor es
extraerlo. Es la única modalidad de tratamiento que puede,
de manera independiente, ofrecer la cura para una gran
variedad de tumores sólidos. Los principios básicos de la
resección quirúrgica del cáncer incluyen la extracción de
toda la masa de tumor visible, y esto debe hacerse con un
margen de tejido normal que —por regla general o según la
cantidad de tejido normal circundante al tumor aceptada
como ideal— debe ser de 2 cm. Para alcanzar ese tejido
circundante, tal vez sea necesaria la resección de órganos
adyacentes.
Not infrequently we have to evaluate margins at the time of
surgery to be sure that not only all the macroscopic tumor is
removed, but the microscopic tumor as well. We fairly
liberally use intraoperative assessment, but depending --but there are some restrictions that may help guide whether
to use intra-operative assessment, because it is time
consuming and expensive. An intra-operative assessment is
not going to be helpful if there is no more tissue that can be
taken to improve the margin or if that additional tissue
would cause --- would inflict significant morbidity or
potentially even mortality on the patient. So if you can’t
get any more margin, there is no reason to assess the
margin. If you can get more tissue, then it makes sense to
assess the margin while the patient is still asleep and in the
operating room.
No es infrecuente que debamos evaluar los márgenes en el
momento de la cirugía para asegurarnos de extraer no sólo
todo el tumor macroscópico, sino también el microscópico.
Utilizamos la evaluación intraoperatoria de manera bastante
liberal, pero hay algunas restricciones que pueden
ayudarnos a decidir, ya que se trata de un proceso largo y
perjudicial. La evaluación intraoperatoria no será útil si no
hay más tejido que pueda extirparse para mejorar el
margen, o si su extracción causará una morbilidad
considerable o incluso la muerte del paciente. Si no se
puede aumentar el margen, no hay ninguna razón para
evaluarlo. Si se puede retirar más tejido, evaluamos el
margen mientras el paciente aún está anestesiado en la sala
de operaciones.
4
Treatment Modalities: Surgery
Role of Surgery: Margin Assessment
• Immediate pathologic evaluation (frozen section)
may be required to insure that margin is free of tumor
• Can be difficult to evaluate in setting of pre-surgical
treatment (chemo, XRT)
• Scarring from previous surgery can also make frozen
section evaluation difficult
Treatment Modalities: Surgery
Role of Surgery
• Principles (continued)
– Resection of associated lymph node basin often
required for staging, local control, and/or cure
– Intra-abdominal tumors require node resection
according to the vascular supply/drainage to
the organ
The immediate pathologic evaluation may be required to be
sure that the margin is free of tumor, and I think the most
frequent setting we use this in is breast cancer, because, if
we are doing a partial mastectomy, there is many times that
we can take more tissue to be sure that there is a true
microscopic negative margin. This can be difficult for the
pathologist, because, if patients have gotten preoperative
treatment either chemotherapy or radiation therapy, it can
be much more difficult for them to be able to evaluate
normal tissue from scar tissue from tumor tissue.
Additionally, if patients have had previous surgeries, scar
tissue can make frozen section more difficult to evaluate.
So, it’s not always easy for the pathologist to evaluate
margins while the patient is asleep. Again, it can be very
time consuming and also very expensive.
Puede requerirse una evaluación patológica inmediata para
garantizar que el margen esté libre de tumor y, en mi
opinión, su uso es más frecuente en el cáncer de mama.
En una mastectomía parcial, muchas veces podemos extraer
más tejido para asegurar un verdadero margen
microscópicamente negativo. Esto puede ser difícil para el
patólogo, dado que si la paciente recibió tratamiento
preoperatorio con quimioterapia o radioterapia, no es fácil
diferenciar el tejido normal del cicatricial o tumoral.
Además, si un paciente tuvo una cirugía anterior, el tejido
cicatricial puede dificultar la evaluación de una sección
congelada. No siempre es sencillo para el patólogo evaluar
los márgenes mientras el paciente está anestesiado, y,
reitero, este proceso puede ser muy largo y perjudicial.
The other important role for surgery, which falls into
staging, is evaluation of the lymph node basins. That
frequently is required as I said for staging, but sometimes is
required for local control and in some cases even for cure of
the patient when removing lymph nodes will improve the
outcome. For intra-abdominal tumors like the stomach, the
colon, or the pancreas, the normal resection falls along
according to the vascular supply and drainage of that organ.
La otra función importante de la cirugía, dentro de la
estadificación, es evaluar las cuencas de los ganglios
linfáticos. Aunque suele requerirse para la estadificación, a
veces es necesaria para el control local, y otras para la
curación del paciente cuando los ganglios linfáticos se
extraen a fin de mejorar el resultado. Para los tumores
intraabdominales, como los de estómago, colon o páncreas,
la resección normal se realiza según el suministro vascular
y el drenaje del órgano.
• Stomach
• Colon
• Pancreas
5
Treatment Modalities: Surgery
Treatment Modalities: Surgery
Role of Surgery
• Extremity and trunk tumors often require
evaluation/removal of regional lymph nodes
– Breast
– Melanoma
For trunk or extremities, tumors in the trunk or extremities
like, for example, the breast, there is an orderly drainage
pattern, as you see here, from the area of the tumor to the
lymph node basin.
Para los tumores de las extremidades o el tronco, como los
de mama, hay un patrón de drenaje ordenado, como vemos
aquí, de la zona del tumor a la cuenca de los ganglios
linfáticos.
It is very frequent that these tumors will spread through the
regional lymph nodes like in breast and melanoma. But
there are some tumors that never --- very rarely metastasize
to the lymph nodes, such as sarcoma and hepatocellular
carcinoma and those tumors, because they rarely, so rarely
metastasize to the lymph nodes, do not require a lymph
node evaluation.
Es muy frecuente que los tumores de mama y el melanoma
se propaguen a través de los ganglios linfáticos regionales;
sin embargo, hay otros —como el sarcoma y el carcinoma
hepatocelular— que casi nunca hacen metástasis en los
ganglios linfáticos, por lo cual en estos casos no se requiere
evaluar estos últimos.
• Some tumors do not metastasize via lymph nodes
(therefore, they do not require nodal evaluation)
– Sarcoma
– Hepatocellular carcinoma
6
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
Fine needle aspiration
Core Biopsy
Excisional biopsy
Lymphatic mapping and sentinel
lymph node biopsy
• Lymph node dissection
•
•
•
•
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
• Fine needle aspiration
– Appropriate for evaluation of abnormal appearing
lymph nodes on P.E. and/or ultrasound
– Yields individual cells – can not evaluate structure
or invasion
– R/O metastatic disease
– Often not adequate amount of tissue for complete
pathologic evaluation in patients with hematologic
malignancies
How else can we evaluate lymph nodes if we know there
are abnormal lymph nodes preoperatively? You can do a
fine needle aspiration. You can do a core biopsy. You can
do an excisional biopsy of the lymph node. You can do
lymphatic mapping and sentinel lymph node biopsy, or you
can do a formal lymph node dissection, and we will talk
about each of these individually.
¿De qué otra manera podemos evaluarlos si antes de la
operación ya sabemos que algunos son anormales?
Es posible hacer una aspiración con aguja fina, una biopsia
con aguja gruesa o una biopsia por escisión de los ganglios
linfáticos; también un mapeo linfático y una biopsia del
ganglio centinela, o una disección formal de los ganglios
linfáticos. Veamos cada caso individualmente.
So, fine needle aspiration is appropriate for evaluating
abnormal appearing lymph nodes that are either present on
physical exam, ultrasound, or other imaging methods. The
problem with fine needle aspiration is it gives you only
individual cells. So it can’t tell you anything about the
structure of the organ or whether there is invasion or not. It
can help you to rule out metastatic disease. One other
problem is that often you do not have adequate amount of
tissue for a complete pathologic evaluation of patients that
have hematologic malignancies, so you may be able to get a
preliminary evaluation, but not enough information to be
able to do a definitive treatment plan. Again, it may not be
enough tissue, because you are only getting individual cells,
to get a complete histologic diagnosis.
La aspiración con aguja fina es apropiada para evaluar los
ganglios linfáticos de aspecto anormal detectados con un
examen físico, pruebas de ultrasonido o por imágenes.
La aspiración con aguja fina sólo extrae células
individuales; por eso, no informa la estructura del órgano o
si hay invasión, pero ayuda a descartar una enfermedad
metastásica. A menudo no se tiene una cantidad de tejido
adecuada para una evaluación patológica completa de
condiciones hematológicas malignas, pero es posible hacer
una evaluación preliminar, aunque sin información
suficiente para planificar un tratamiento definitivo. Tal vez
no haya suficiente tejido para un diagnóstico histológico
completo, ya que sólo se obtienen células individuales.
– Not always enough tissue for complete histologic
diagnosis (i.e. subtyping of tumor)
7
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
• Excisional biopsy
– Provides more tissue for pathologic evaluation
• Complete removal of gross tumor
An excisional biopsy provides more tissue for pathologic
evaluation. An excisional biopsy is a complete removal of
the gross tumor. It is helpful in cases that are difficult to
diagnose by needle biopsy, and for many hematologic
malignancies, it is necessary to have the complete structure
of the lymph node, for example, to be able to get a full
pathologic evaluation.
La biopsia por escisión extrae más tejido para una
evaluación patológica. Consiste en la extirpación completa
de la masa de tumor, y es útil en casos difíciles de
diagnosticar por biopsia con aguja. En muchas condiciones
malignas hematológicas se necesita toda la estructura del
ganglio linfático para obtener una evaluación patológica
completa.
Lymphatic mapping and sentinel node biopsy is a procedure
that now has been in practice for about 10 years. It is based
on the fact that there is a reproducible orderly drainage of
lymphatics in almost all cases from the primary tumor.
And the first lymph node in that regional chain is called the
sentinel lymph node. Because of this orderly drainage, the
sentinel lymph node is that tumor --- that lymph node that is
most likely to harbor metastatic tumor cells.
El mapeo linfático y la biopsia del ganglio centinela es un
procedimiento que se ha realizado durante unos 10 años y
se basa en el hecho de que, en casi todos los casos, hay un
drenaje ordenado y reproducible de los vasos linfáticos
desde el tumor primario. El primer ganglio linfático de esa
cadena regional se denomina “ganglio linfático centinela”.
Debido a este drenaje ordenado, el ganglio linfático
centinela es el que más probablemente aloja las células
tumorales metastásicas.
– Helpful in cases difficult to diagnose by needle
biopsy
– Frequently required for full pathologic evaluation of
hematologic malignancies
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
• Lymphatic Mapping (LM) and Sentinel Lymph
Node (SLN) Biopsy
– Reproducible orderly drainage of lymphatics from
primary tumor
– First lymph node in regional chain = Sentinel lymph node
(SLN)
– SLN most likely to harbor metastatic cells
8
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
• Lymphatic Mapping (LM) and Sentinel Lymph
Node (SLN) Biopsy
– Originally described for carcinoma of the penis
– Now standard of care for melanoma and invasive
breast cancer
It was originally described for patients with carcinoma of
the penis, but has really become the standard of care for
melanoma and invasive breast cancer. It is an extremely
accurate staging tool. If there is no tumor in the sentinel
lymph node then there is no need to do further nodal
removal in those diseases. On the other hand, if there is a
tumor in the sentinel lymph node, then it may be necessary
to perform further evaluation of the remainder of the lymph
node basin.
Esta técnica fue descrita inicialmente en pacientes con
carcinoma de pene, pero se ha convertido en el cuidado
estándar para el melanoma y el cáncer de mama invasivo.
Es una herramienta muy precisa para la estadificación.
Si no hay tumor en el ganglio linfático centinela, con esas
enfermedades no hay necesidad de extraer más ganglios.
Pero si hay tumor en el ganglio linfático centinela, quizás
sea necesaria una mayor evaluación del resto de la cuenca.
That evaluation will be done by a formal lymph node
dissection. And a lymph node dissection is removal of the
majority of a lymph node basin. There are several purposes
to a lymph node dissection. It provides local control for
patients with --- that have metastases that have been
documented in the sentinel lymph node. It gives more
accurate staging, so you know the number of lymph nodes
that are involved when --- or if a sentinel node biopsy does
not work. There are times about 10% of --- less than 10%
of the time that sentinel lymph node biopsy is not
successful, where you cannot find the sentinel lymph node.
So, you may need to do a lymph node dissection in order to
be able to get an accurate lymph node evaluation. The
difference between a sentinel lymph node biopsy and a
lymph node --- a formal lymph node dissection is that there
is a significant increase in the morbidity in post-op recovery
with a formal lymph node dissection. The recovery is
significantly longer and more morbid.
La evaluación se realiza con una disección formal de los
ganglios linfáticos, extirpando la mayor parte de una
cuenca. La disección de estos ganglios tiene varios
objetivos. Permite controlar localmente a pacientes con
metástasis documentada en el ganglio linfático centinela.
Ofrece una estadificación más exacta, ya que indica la
cantidad de ganglios linfáticos involucrados o si la biopsia
del ganglio centinela no es eficaz. En menos del 10% de los
casos, la biopsia del ganglio centinela no tiene éxito porque
no se lo puede localizar. Por lo tanto, para poder hacer una
evaluación precisa de los ganglios linfáticos, es posible que
se deba hacer su disección. La diferencia entre una biopsia
del ganglio centinela y una de ganglio linfático —una
disección formal del ganglio linfático— es que esta última
aumenta considerablemente la morbilidad en la
recuperación postoperatoria. La recuperación es bastante
más prolongada y más mórbida.
• Accurate staging tool
• If SLN does not contain tumor, then no need for further
nodal removal in those diseases
Treatment Modalities: Surgery
Role of Surgery: Lymph Node Evaluation
• Lymph node dissection
– Provides local control for patients with metastases
in SLN
– Provides accurate staging for patients in whom SLN
biopsy is not feasible
– Significant increase in morbidity and post-operative
recovery compared to SLN biopsy
9
Treatment Modalities: Surgery
Role of Surgery: Neoadjuvant Treatment
• Both chemotherapy and radiotherapy can both
be used in the neoadjuvant setting
• Initially, concern that surgical morbidity and mortality
would be significantly increased
• The morbidity is increased in some diseases – more
commonly after neoadjuvant radiotherapy – however,
it is not prohibitive
Treatment Modalities: Surgery
Role of Surgery: Neoadjuvant Treatment
• Tumor cytoreduction after neoadjuvant treatment may
convert patients from unresectable to resectable
• Neoadjuvant treatment can help reduce the extent
of surgery
– This can result in an increase in organ preservation
• Breast preservation rate in breast cancer
• Sphincter preservation rate in rectal cancer
Another area that we use surgery is after patients have
received neoadjuvant treatment. Both chemotherapy and
radiation therapy are often used in the neoadjuvant setting,
sometimes even together. Initially, there was concern that
the use of surgery after neoadjuvant treatment would
increase morbidity and mortality, and in some cases that is
true, especially after neoadjuvant radiation therapy.
However, most studies have shown that, for the diseases
that we use neoadjuvant radiation therapy, that risk --- that
increase in morbidity is not prohibitive.
Otro caso en el que utilizamos cirugía es cuando los
pacientes han recibido tratamiento neoadyuvante. Tanto la
quimioterapia como la radioterapia suelen utilizarse en este
tratamiento, incluso juntas. Inicialmente existía la
preocupación de que la cirugía después del tratamiento
neoadyuvante aumentaría la morbilidad y la mortalidad.
En algunos casos es cierto, sobre todo después de la
radioterapia neoadyuvante; sin embargo, la mayoría de los
estudios demuestran que, para las enfermedades con
radioterapia neoadyuvante, el riesgo de aumento de
morbilidad no es prohibitivo.
The purpose of neoadjuvant treatment is to reduce the
tumor size and bulk. This tumor cytoreduction may allow
for some patients to go from being unresectable to
resectable. And we see that with chemoradiation for rectal
cancer; we see it for patients with metastatic colorectal
cancer to the liver, as two examples of diseases that, not
infrequently we see good responses to neoadjuvant
treatment and enough tumor cytoreduction to allow a
change in surgical strategy. It also can reduce the extent of
surgery, and this is a way that we increase organ
preservation. And again, very classically this has been
done in breast cancer. And it has allowed us to do breast
conservation in patients who have large tumors by giving
them pre-operative chemotherapy --- neoadjuvant
chemotherapy. We can reduce the size of tumors and allow
them to have partial mastectomies as opposed to total
mastectomies. Additionally, it has been very clearly shown
in a number of studies that we can increase the sphincter
preservation rate in rectal cancer with neoadjuvant
chemoradiation therapy, and that is solely because we
decrease the bulk of the tumor, which allows the surgery to
El propósito del tratamiento neoadyuvante es reducir el
tamaño y la masa del tumor. Esta citorreducción tumoral
puede permitir la resección en algunos pacientes en quienes
no era posible. Ocurre con la quimiorradioterapia de cáncer
rectal y también en pacientes con cáncer colorrectal
metastásico en el hígado, dos ejemplos de enfermedades
que en no pocas veces registramos buenas respuestas al
tratamiento neoadyuvante y una citorreducción del tumor
suficiente para cambiar la estrategia quirúrgica. También
puede reducir la extensión de la cirugía, y esto aumenta la
preservación de los órganos. Una aplicación clásica ha sido
el cáncer de mama, donde permite conservar la mama en
pacientes con tumores de gran tamaño, aplicando
quimioterapia
preoperatoriamente
—quimioterapia
neoadyuvante—. Al reducir el tamaño de los tumores
podemos utilizar una mastectomía parcial en lugar de total.
Una serie de estudios demostró claramente que la
quimiorradioterapia neoadyuvante aumenta la tasa de
preservación del esfínter en el cáncer rectal. Eso se debe
exclusivamente a que al disminuir la masa del tumor, la
cirugía es un poco más sencilla y se logra preservar mejor
10
Treatment Modalities: Surgery
Role of Surgery: Tumor Debulking
• Tumor debulking is rarely indicated
• Unlikely to alter patient outcome in solid tumor
malignancies
be a little easier and more readily accomplished in terms of
being able to save the sphincters.
Well, since we can make tumors smaller, the question often
arises does it make sense to debulk tumors and take out part
of tumors. In general, it is felt that tumor debulking is not
indicated. It is unlikely to alter patient outcome in any solid
tumor malignancy. And it is frequently associated with
significant morbidity and mortality, because it is hard to
define tissue planes when you are cutting through tumor or
you are only taking out parts of tumor.
los esfínteres.
The only disease where it has been shown to be beneficial
to do tumor debulking is in patients with pseudomyxoma
peritonei. In those patients, neoadjuvant --- I’m sorry,
tumor debulking has been shown in combination with
intraperitoneal chemotherapy to both prolong survival and
decrease ascites.
La única enfermedad en que se ha comprobado que la
citorreducción del tumor es beneficiosa es el
pseudomixoma peritoneal. En estos pacientes, la
citorreducción, combinada con la quimioterapia
intraperitoneal, prolonga la supervivencia y disminuye la
ascitis.
Si podemos reducir el tamaño de los tumores, ¿tiene sentido
citorreducirlos y luego extraerlos parcialmente? En general,
se considera que la citorreducción de un tumor no está
indicada. Es improbable que modifique los resultados de los
pacientes con tumores malignos sólidos. Además, suele
asociarse a morbilidad y mortalidad considerables, ya que
es difícil definir los planos tisulares cuando un tumor se
corta o sólo se extrae parcialmente.
• Frequently associated with significant morbidity
and mortality
Treatment Modalities: Surgery
Role of Surgery: Neoadjuvant Treatment
• Has been shown to be beneficial in conjunction with
intraperitoneal chemotherapy in patients with
pseudomyxoma peritonei
– Prolonged survival
– Decreased ascites
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Treatment Modalities: Surgery
Role of Surgery: Neoadjuvant Treatment
• Benefit and role controversial in ovarian cancer
• No proven role/benefit in patients with sarcomatosis
• No proven role/benefit in patients with carcinomatosis
– Gastric cancer
– Colorectal cancer
– Pancreatic cancer
Treatment Modalities: Surgery
Role of Surgery: Palliation
• Surgical treatment should be reserved for the
alleviation of symptoms
• Can not provide “palliation” if there are no symptoms
• Must weigh benefits of intervention vs. cost of
invasive procedure
– Pain from procedure
– Possible hospitalization required
– Possible complications
There have been questions about the role for tumor
debulking in ovarian cancer and carcinomatosis. In ovarian
cancer, it is the other disease that has been really frequently
evaluated, the role and the benefit of debulking surgery and
intraperitoneal chemotherapy in ovarian cancer really
remains controversial at this time. In patients with
multifocal sarcomas throughout the abdominal cavity, so
called sarcomatosis, there really has been no proven role of
benefit in those patients to debulking tumors. In patients
with carcinomatosis, for example, from gastric cancer and
pancreatic cancer as well as colorectal cancer, again there
has been no good proven role or benefit for debulking those
patients and/or using intraperitoneal chemotherapy.
Existen dudas sobre la función de la citorreducción tumoral
en el cáncer de ovario y la carcinomatosis. El cáncer de
ovario es la otra enfermedad en que se ha evaluado
frecuentemente, y la función y el beneficio de la cirugía
citorreductora y la quimioterapia intraperitoneal en este tipo
de cáncer siguen siendo muy controvertidos. En pacientes
con sarcomas multifocales en toda la cavidad abdominal,
una condición llamada sarcomatosis, la citorreducción
tumoral no ha demostrado ninguna función o beneficio.
En pacientes con carcinomatosis de cáncer gástrico, de
páncreas y colorrectal tampoco se ha demostrado ninguna
función o beneficio con la citorreducción o el uso de
quimioterapia intraperitoneal.
Another important role for surgery is the palliation of
patients with cancer. We really feel pretty strongly that
surgical treatment should be reserved for the alleviation of
symptoms. Reducing the bulk of tumor does not improve
outcome or increase survival. So, the surgical dogma is you
can’t palliate something if there is nothing to palliate. So, if
the patient is asymptomatic, you cannot improve that. You
can only improve on somebody --- a patient’s symptoms.
So, if there are no symptoms, you can’t palliate them. It is
probably one of the most difficult decisions to make in
surgery, deciding whether the benefit of intervening
palliatively from a surgical standpoint outweighs the cost
and benefit of an invasive procedure. You have to take into
account, there’s pain that you introduce from a surgical
procedure. Most likely, they will require a hospitalization.
And the worse scenario is, if a patient develops a
complication when you are doing palliation and has the
ultimate worse outcome, even a death. So, though all of
those are very difficult things to measure and predict,
making it much more difficult --- making it a much more
difficult decision as to when to do palliative surgery.
Otro papel importante de la cirugía es el tratamiento
paliativo de pacientes con cáncer. Estamos convencidos de
que el tratamiento quirúrgico debe reservarse para aliviar
los síntomas. Reducir la masa del tumor no mejora el
resultado ni la supervivencia. El dogma quirúrgico es que
no se puede paliar algo si no hay nada que paliar. Si el
paciente está asintomático, su condición no se puede
mejorar. Sólo es posible mejorar los síntomas, y si no los
hay, no se pueden paliar. Esta probablemente sea una de las
decisiones más difíciles respecto a la cirugía: decidir si el
beneficio de intervenir paliativamente desde el punto de
vista quirúrgico excede los perjuicios de un procedimiento
invasivo. Hay que tener en cuenta el dolor que se inflige
con un procedimiento quirúrgico. Lo más probable es que el
paciente deba ser hospitalizado, y el peor escenario es que
el cuidado paliativo derive en una complicación con un
resultado más desfavorable, incluso la muerte. Todo esto es
difícil de medir y predecir, y la decisión se complica aún
más al determinar cuándo hacer una cirugía paliativa.
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Treatment Modalities: Surgery
Role of Surgery: Palliation
• Should alleviate symptoms using least invasive
method available
– Endoscopy > Laparoscopy > Laparotomy
• Stent may be better than colostomy
• Nerve block may be better than resection
• Percutaneous gastrostomy tube may be better than
surgically placed tube
• “Best” intervention may be no intervention
Again, alleviating symptoms is the main role for palliation,
and we feel strongly that we should use the least invasive
methods possible to be able to alleviate those symptoms.
So, for example, if you can do something endoscopically, it
is better than doing something even laparoscopically, which
is better than doing something with open surgery. The least
surgery the better. So, for example, if a patient has an
obstructing colon cancer, a stent placed endoscopically may
relieve the obstruction and avoid a laparotomy or
laparostomy or avoid a colostomy. Most patients would
prefer not to have a colostomy bag even if they know it’s
terminal --- you know, part of their terminal event. It is
very a difficult thing to convince a patient that a colostomy
bag would be in their benefit. If patients are having pain,
sometimes things like nerve blocks or regional anesthesia
can be used for local control as opposed to resecting the
tumor. Again, if you are not going to change the survival,
putting a patient through a large operation that could have a
large morbidity due to blood loss, functional debility, etc.,
would not be as big a benefit as if you could control the
pain with either pain medication, nerve block, regional
anesthesia, or some other less invasive procedure.
Frequently, we are asked to help patients who have
blockages of their intestinal tracts by placing gastrotomy
tubes or feeding jejunostomy tubes. If those tubes can be
placed percutaneously, either by endoscopic techniques or
interventional radiology --- radiologic techniques, that’s
better than having the patient have to have an open
laparotomy, which again requires more anesthetic time,
possibly a hospitalization and the risk of more --- higher
risk of complications. We have to understand that
sometimes the best intervention may be no intervention. It
may be that doing nothing may be the best thing in the
palliative setting.
La función principal de la paliación es aliviar los síntomas,
y estamos convencidos de que debemos utilizar los métodos
menos invasivos posibles. Si una intervención puede
hacerse por endoscopia, es mejor que por laparoscopia, que
a su vez es mejor que la cirugía abierta. Cuanta menos
cirugía, tanto mejor. Si un paciente tiene cáncer de colon
obstructivo, colocar un stent endoscópicamente puede
aliviar la obstrucción y evitar una laparotomía o
laparostomía, o una colostomía. La mayoría de los
pacientes prefieren no tener una bolsa de colostomía,
aunque sepan que se trata de una condición terminal.
Es muy difícil convencerlos de que una bolsa de colostomía
los beneficia. Si sienten dolor, a veces es posible utilizar un
bloqueo nervioso o anestesia regional para obtener control
local en lugar de resecar el tumor. Si no se va a modificar la
supervivencia, someter a un paciente a una operación
importante que podría tener una gran morbilidad por
pérdida de sangre, debilidad funcional, etc., no ofrecería un
beneficio tan grande como poder controlar el dolor con
analgésicos, bloqueo nervioso, anestesia regional u otro
procedimiento menos invasivo. Con frecuencia se nos pide
que ayudemos a los pacientes con obstrucción de tracto
intestinal colocándoles tubos de gastrotomía o tubos de
alimentación de yeyunostomía. Si esos tubos pueden
colocarse por vía percutánea, ya sea mediante técnicas
endoscópicas o radiológicas intervencionistas, son una
mejor opción que someter al paciente a una laparotomía
abierta, la cual requiere más tiempo de anestesia y
posiblemente hospitalización, y que además presenta un
mayor riesgo de complicaciones. Debemos comprender
que, a veces, la mejor intervención puede ser la no
intervención, y que tal vez no hacer nada sea lo mejor en el
contexto paliativo.
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Treatment Modalities: Surgery
Role of Surgery: Metastatectomy
• Traditionally, surgery is not the first line treatment
modality for metastatic disease
• Non-operative treatment modalities should be
considered before surgical intervention
• Multiple sites of metastatic disease only treated with
surgery to palliate symptoms
– Bowel obstruction
– Symptomatic brain metastasis
Treatment Modalities: Surgery
Role of Surgery: Metastatectomy
• Isolated metastatic disease may be resected
for potential cure
• Observed period of stability or response while
on systemic treatment, often can help predict benefit
to resection
– Lung metastasis from sarcoma
– Liver metastasis from colorectal cancer
– Brain metastasis from melanoma
Another frequent expanded role for surgery has been the
role for surgery in patients with metastatic disease. And
traditionally surgery was not felt to be indicated and
certainly was not the first line of treatment for patients with
metastatic disease, because it was felt that surgery alone,
once the tumor has spread from its primary site, was not
going to be curative. So why put a patient through a large,
potentially painful, difficult recovery if you are not going to
be curing the patient? And it was always felt that nonoperative treatment modalities should be considered before
doing an operative intervention. When patients have
multiple sites of disease, we really think that it is extremely
rare that surgery could be of benefit in those patients. So,
surgery should be limited to again palliation, as we already
discussed. So, for example, if somebody has a bowel
obstruction, relieving that bowel obstruction, surgery may
be the only way to do that. Patients with symptomatic brain
metastasis, again surgery might be the only, or the best
potential mechanism for treating those symptoms.
On the other hand, when the patients have isolated
metastatic disease, it is possible that a subset of those
patients can be cured by resecting the metastatic disease.
So, how do we know who to resect and who not to resect
when there is metastatic disease? There is no good
scientific data to say who should be resected and who
should not be resected. We think that, if there is a period of
stability or response while the patient is on systemic
treatment, that might help predict who is going to benefit
from resection. So, again with metastatic disease the best
primary treatment is systemic treatment, chemotherapy or
biologic therapy. If we see a response or the stabilization of
tumor in those cases, then it may be that those patients have
a favorable biology and will benefit by taking out the tumor
then. So, some examples of situations where we use
selective surgery for isolated metastatic disease are in
patients with sarcoma who we see respond to
chemotherapy. We might do resection of their lung
Otra función frecuente y ampliada de la cirugía es en
pacientes con enfermedad metastásica. Tradicionalmente, la
cirugía no se consideraba indicada y, por cierto, no era la
primera línea de tratamiento para la enfermedad
metastásica, ya que una vez que el tumor se hubiera
diseminado desde su sitio principal, la cirugía sola no sería
curativa. Entonces, ¿por qué someter a un paciente a una
recuperación prolongada, posiblemente dolorosa y difícil si
no lograremos curarlo? Siempre se pensó que antes de una
intervención quirúrgica era preciso considerar modalidades
de tratamiento no quirúrgicas. Cuando los pacientes tienen
enfermedad en múltiples sitios, es muy inusual que la
cirugía resulte beneficiosa. La cirugía debe limitarse a la
paliación. Si una persona tiene obstrucción intestinal, tal
vez la cirugía sea la única manera de aliviarla, y en
pacientes con metástasis cerebrales sintomáticas, podría ser
el mejor mecanismo posible —o el único— para tratar los
síntomas.
Por el contrario, en la enfermedad metastásica aislada, es
posible que un subconjunto de pacientes pueda curarse
mediante la resección de las metástasis. ¿Cómo decidir
cuándo realizarla? No tenemos datos científicos válidos
para decirlo. Si hay un período de estabilidad o respuesta
mientras el paciente recibe tratamiento sistémico, ese factor
podría predecir quiénes se verán beneficiados con la
resección. En la enfermedad metastásica, el mejor
tratamiento primario es el sistémico, la quimioterapia o la
terapia biológica. Si en estos casos observamos una
respuesta o la estabilización del tumor, es posible que los
pacientes tengan una biología favorable y se vean
beneficiados con la extracción del tumor. Un ejemplo de
situaciones en las que empleamos cirugía selectiva para
enfermedad metastásica aislada son los pacientes con
sarcoma que responden a la quimioterapia. Podríamos hacer
una resección de las metástasis de pulmón. Uno de los
casos más comunes es el de pacientes con cáncer
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Treatment Modalities: Surgery
Role of Surgery: Complications
• Acute
– Defined as occurring within 30 days of surgery
– May be anesthesia/surgery related
• Pneumonia
• UTI
• Venous thrombosis
– May be direct consequence of surgical procedure
• Abscess
• Fistula
• Hemorrhage
metastasis. One of the most common things that we see is
patients with colorectal cancer and liver metastasis. We
used to say that the limit for a liver resection was for
metastasis, and now we have kind of expanded that limit to
we don’t know what the upper limit should be. We think
that, if patients are responding and their tumors are
respectable, that they potentially could benefit from
resection. There have been several studies to show that
there is even a survival benefit in those --- that group of
patients. So, if you see a response, or even a stabilization,
because stabilization is a response, tumors don’t necessarily
just have to shrink. If the tumor stops growing that means
it has responded to the treatment. So, if there is some sign
of response to systemic treatment, resecting those tumors
may be reasonable. And, again, in patients with brain
metastasis for melanoma, another disease where we may be
able to show benefit in both survival and outcome in those
patients [is] by resecting that disease.
One issue that I have alluded to several times is that surgery
comes with potential downsides, and you can’t do surgery
without the potential of having complications. We really
define surgery --- surgical complications into acute and
chronic. Acute surgical complications are defined as those
that occur within 30 days of the operation. They could be
related to the anesthesia and the surgery, such as
pneumonia, urinary tract infections, or venous thrombosis
are some of the more common complications that we see in
the early postoperative period. They may be related to
surgery itself, like an abscess, a fistula, or bleeding. All of
these are problematic, delay recovery, and even more
significantly can potentially delay systemic or adjuvant
systemic treatment or radiation treatment.
colorrectal y metástasis hepática. Solíamos decir que el
límite para una resección de hígado era la metástasis, pero
ahora lo hemos ampliado y ya no sabemos cuál es el límite
superior. Si un paciente está respondiendo y sus tumores
son importantes, posiblemente se vea beneficiado con la
resección. Varios estudios incluso demuestran un beneficio
de supervivencia en ese grupo de pacientes. Si se
comprueba una respuesta, o aun una estabilización —que
en sí misma es una respuesta—, los tumores no
necesariamente tienen que reducirse. Si el tumor deja de
crecer, ha respondido al tratamiento. Si hay una señal de
respuesta al tratamiento sistémico, resecarlo puede ser una
medida razonable. Los pacientes con metástasis cerebrales
de melanoma son otro caso en que la resección de la
enfermedad ha demostrado beneficios en lo que se refiere
tanto a la supervivencia como al resultado.
Varias veces he mencionado que la cirugía tiene posibles
inconvenientes y que no se puede realizar sin la posibilidad
de complicaciones, que pueden ser agudas o crónicas. Las
complicaciones quirúrgicas agudas son las que ocurren
dentro de los 30 días de la operación. Pueden relacionarse
con la anestesia y la cirugía, como neumonía, infecciones
del tracto urinario o trombosis venosa, que son algunas de
las más comunes en el período postoperatorio inicial.
También pueden relacionarse con la cirugía en sí, como
abscesos, fístulas o sangrado. Todas estas condiciones son
problemáticas, retrasan la recuperación y, lo que es más
importante, pueden posponer el tratamiento sistémico o
sistémico adyuvante, o la radioterapia.
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Treatment Modalities: Surgery
Role of Surgery: Complications
• Chronic
– Defined as occurring/continuing more than 30 days
after surgery
– Examples include
• Lymphedema
• Pain syndromes
• Urinary/bowel incontinence
Treatment Modalities: Surgery
Conclusions
• Surgery plays an important role in the diagnosis,
staging and treatment of cancer
• In addition to rendering a patient disease free,
surgery may be beneficial in providing palliation for
select patients
Chronic complications are defined as those that occur or
continue for more than 30 days after surgery, and some of
the more common things we see are, for example,
lymphedema after a lymph node dissection in the extremity.
Not uncommonly we can see patients with pain syndromes
when there is neurologic involvement of a tumor that has
been resected. And then bowel and bladder dysfunction can
happen after pelvic surgery, not uncommonly. There is not
--- very frequently a change in bladder and bowel habits
after both bladder or rectal surgery, and those can be for the
patient’s entire lifetime, a different change in their bowel
patterns or urinary patterns.
Las complicaciones crónicas son aquellas que ocurren o
continúan por más de 30 días después de la cirugía, y
algunas de las más comunes son el linfedema en la
extremidad en que se realiza una disección de ganglios
linfáticos. No son infrecuentes los síndromes de dolor
cuando se ha realizado la resección de un tumor y el
aspecto neurológico se ha visto afectado. Tampoco es
infrecuente que la cirugía pélvica produzca una disfunción
de los intestinos y la vejiga. Después de la cirugía intestinal
o rectal, a menudo hay un cambio en los hábitos urinarios o
intestinales, que pueden durar toda la vida y alterar los
patrones intestinales o urinarios.
So, in summary, surgery plays an important role in both the
diagnosis, the staging, and the treatment of cancer, more so
in solid tumors but also an important role in hematologic
malignancies as well. In addition to rendering a patient
disease free from their tumor, surgery may be beneficial in
providing effective palliation for selected patients. Surgery
can result in both acute and chronic complications. I would
like to thank you for your time, and please do not hesitate to
contact us if there should be any questions regarding this
lecture. Thank you very much.
En resumen, la cirugía tiene una importante función en el
diagnóstico, la estadificación y el tratamiento del cáncer,
más aún en los tumores sólidos, y también en gran medida
en las condiciones hematológicas malignas. Además de
librar al paciente de su tumor, puede ser beneficiosa como
paliativo eficaz en ciertos pacientes, aunque puede dar lugar
a complicaciones, tanto agudas como crónicas.
Le agradezco que me haya dedicado su tiempo. Si tiene
alguna pregunta sobre esta disertación, no dude en
comunicarse con nosotros. Gracias otra vez.
• Surgery can result in both acute and chronic
complications
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