Removing a cancerous tumor

Surgical removal of a cancerous tumor remains the most common. It is used for almost all oncological diseases as an independent method, as well as in combination with radiation and drug therapy. At the same time, removal of a cancerous tumor in oncological patients should be performed according to special rules, failure to comply with which entails unsatisfactory long-term treatment results, i.e. a reduction in the life expectancy of patients.

The basic rules for performing operations in oncology are adherence to ablastics and antiblastics, which are aimed at preventing the dissemination and implantation of cancer cells in the wound, which are the cause of relapses and metastases.

Ablasty is understood as tumor removal within healthy tissues in accordance with the principles of anatomical zonality and case. Cancerous tumor should be removed as a single block within an anatomical zone, in a whole case formed by fascial, peritoneal, pleural sheets and fatty tissue. An anatomical zone is a biologically whole area of tissue formed by an organ or its part and its regional lymph nodes and other anatomical structures lying on the path of tumor spread. The external boundaries of the anatomical zone are determined by such landmarks as the junction of fascial sheets, peritoneal sheets, and wide layers of fatty tissue. These layers form a kind of wall of the case, beyond which tissue should be isolated. Blood vessels entering or leaving the case zone intersect beyond its limits.

Antiblastika involves the destruction of remaining tumor cells in the wound. Antiblastika includes intraoperative radiation exposure to the bed of the malignant neoplasm, treatment of the surgical field with chemicals, intravenous infusion of chemotherapy drugs during surgery, ligation of the main vessels of the organ before its mobilization, use of a laser scalpel, etc.

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How is a cancer tumor removed?

Removal of a cancerous tumor is what determines the ideology of surgical treatment of malignant neoplasms and forms the philosophy of a surgical oncologist. Modern principles of oncosurgery were formulated by the leading surgical oncologist of the country, director of the Russian Oncologic Research Center (RONC) of the Russian Academy of Medical Sciences (RAMS) named after N.N. Blokhin, president of RAMS M.I. Davydov (2002): "Modern oncosurgery, the strategic goal of which is to increase the duration and quality of life of patients, should be based on the oncologic adequacy of the operation, its safety and the highest possible functionality." The balance of these principles determines the meaning of the surgical method in oncology, and the main tasks, the solution of which will allow achieving the main goal, can be formulated as follows.

• Rational surgical access, providing visually controlled actions of the surgeon and a convenient “angle of attack” at all stages of the intervention, and especially in the event of serious intraoperative complications.
• Minimal risk of local recurrence when planning radical surgical intervention, achieved by adequate resection of the affected and adjacent organs in case of intimate connection with the tumor, regardless of whether this connection is caused by an inflammatory process or invasion, mobilization of the complex "acutely" within the fascial sheaths - from the borders of the excised block to the affected organ ("en block" - resection), separate treatment of vessels, a well-thought-out sequence and techniques of mobilization with minimal mechanical impact on the tumor to its vascular and lymphatic isolation ("no touch" - surgical technique), as well as adequate in terms of both volume and surgical technique of preventive lymph node dissection, based on the patterns of lymphogenous metastasis.
• Preventive lymph node dissection, the meaning of which can be defined as the planned excision of regional lymph collectors before the start of surgical treatment, is an integral condition of an operation that claims to be radical.
• Elimination and prevention of life-threatening complications of neoplasms, as well as the maximum possible removal of a cancerous tumor as a condition for more effective conservative treatment and ensuring a better quality of life for patients when planning palliative surgeries.
• Expansion of indications for performing operations on primary multiple malignant tumors, on tumors with invasion of vital organs and main vessels, in elderly patients, patients with severe pathology of the cardiovascular system.
• An optimal method of reconstruction in terms of its physiological parameters using simple, reliable and functionally advantageous anastomoses, guaranteeing the social rehabilitation of operated patients.

Removal of a cancerous tumor is absolutely indicated in the presence of a neoplasm within the organ or with metastases in regional lymph nodes, complications of the tumor process that threaten the patient’s life (bleeding, obstruction, asphyxia, etc.).

Relative indications for surgical intervention are given in cases where the therapeutic effect can be achieved with the help of radiation or drug therapy.

Removal of a cancerous tumor is contraindicated in oncological and somatic cases. Oncological contraindications are distant metastasis or tumor growth into non-removable anatomical structures. Somatic contraindications to surgery occur in patients with decompensation of the function of vital organs (pronounced concomitant pathology, old age, etc.).

In oncology, the following concepts are distinguished: operability, inoperability, resectability. Operability is a patient's condition that allows for the removal of a cancerous tumor. Inoperability is a condition in which the removal of a cancerous tumor is impossible due to a threat to the patient's life. Resectability implies the possibility of removing the neoplasm. This issue is resolved during revision during surgery. The result often depends on the qualifications of the operating surgeon. In this case, the cause of inoperability (distant metastases, invasion into neighboring organs and tissues) must be proven morphologically.

Surgical interventions in oncology are divided into diagnostic and therapeutic. Diagnostic operations are performed when it is not possible to obtain a complete description of the tumor process before the operation, including morphological characteristics. Sometimes this is only possible during partial mobilization of the organ (for example, in case of gastric cancer growing into the retroperitoneal tissue).

Removal of cancerous tumor: types

Therapeutic operations are divided into radical, conditionally radical and palliative removal of a cancerous tumor. The concept of "radicalism of an operation" is considered from biological and clinical positions. From a biological position, the degree of radicalism of an operation can only be assessed by life expectancy. A clinical idea of radicalism is formed on the basis of immediate results of the intervention, if the surgeon manages to remove a cancerous tumor within healthy tissues together with regional lymph nodes. This is possible with neoplasms of stages I-II. Clinically, conditionally radical operations are those in which, despite the widespread process, it is possible to remove a cancerous tumor with regional lymph nodes. In such a situation, the surgeon cannot be sure that all tumor cells have been removed. As a rule, this occurs with widespread tumors of stage III.

Radical and conditionally radical operations are divided by volume into typical, combined, and extended. Typical operations include those in which regional lymph nodes are removed along with resection or extirpation of the organ in which the tumor is localized. Combined operations are those in which adjacent organs into which the tumor grows are removed or resected along with resection or extirpation of the affected organ. Extended operations are those in which, in addition to the affected organ and regional lymph nodes, all accessible lymph nodes with tissue in the area of the operation are removed. Extended operations are often performed to increase radicalism in widespread tumor processes.

In addition to the listed radical operations, palliative removal of cancerous tumors is also quite often used in oncology. There are two types: eliminating complications caused by the tumor, and palliative resections. After such operations, tumor tissue remains.

Recently, two trends in the development of oncological surgery have been clearly visible: expansion and reduction of the volume of surgical interventions.

The high frequency of combined and extended surgeries is due to the significant proportion of locally advanced tumors. This is facilitated by the experience accumulated over many years, detailed development of surgical intervention techniques, the introduction of new technologies and advances in anesthesiology and intensive care. By expanding the boundaries of surgical intervention in a larger number of patients with advanced tumors, it is possible to improve the long-term treatment results. A necessary component of this approach is the active use of reconstructive and plastic surgery methods to restore the removed tissues.

The second trend in modern oncological surgery is the reduction of the volume of operations or their abandonment in order to preserve the affected organ and damage the tumor in it using radiation or chemotherapy.

The departure from aggressive surgical tactics in organ-preserving treatment can be explained by the following reasons: revision of clinical and biological concepts of the course of the tumor process; improvement of methods of clarifying instrumental diagnostics; an increase in the number of patients with initial (I-II) stages of cancer; the creation of an effective combination of surgical intervention with radiation and drug exposure; the creation of optimal conditions for rehabilitation and improvement of the quality of life of patients.

In organ-preserving surgeries, modern physical factors are widely used: high-intensity lasers, low-frequency ultrasound, plasma flows of inert gases and various combinations thereof. This allows for increased ablasticity of surgical intervention, increased life expectancy of patients and improved cosmetic and functional results.

In recent decades, laparoscopic removal of cancerous tumors has been increasingly introduced into everyday oncological practice. Laparoscopic operations are used to treat tumors of the urinary tract, genitals, colon and other localizations. The advantages of laparoscopic access are low trauma, reduced rehabilitation periods for patients, reduced hospital stay and a good cosmetic effect. According to surgeons who are proficient in the technique of laparoscopic operations, long-term treatment results do not suffer if the indications for it are correctly stated.

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