Key points
- Decide the intent first: cure or palliation.
- Neoadjuvant treatment comes before surgery; adjuvant treatment after.
- Oncological surgery removes the tumour with clear margins and its lymph nodes, en bloc.
- Immunotherapy can cause colitis, hepatitis and endocrine failure that mimic surgical problems.
Intent
Curative treatment aims to remove every cancer cell and accepts more risk. Palliative treatment aims to control symptoms and extend good-quality life. Saying which one you are aiming for, to the team and the patient, shapes every other choice.
The principles of cancer surgery
- Remove the tumour en bloc with a clear margin (R0), without breaching it.
- Remove the draining lymph nodes for staging and control: D2 gastrectomy, total mesorectal excision for rectal cancer, complete mesocolic excision.
- Handle the tumour as little as possible; ligate the vessels at their origin where appropriate.
- Prophylactic surgery prevents cancer in carriers (FAP, RET, CDH1, BRCA).
- Palliative surgery relieves obstruction, bleeding or pain: bypass, stoma, stent.
- Metastasectomy in selected patients: colorectal liver and lung metastases.
Timing of other treatments
| Term | Meaning | Examples |
|---|---|---|
| Neoadjuvant | Before surgery: shrinks the tumour, treats micrometastases early, tests the response | Locally advanced rectal and oesophageal cancer, gastric cancer, HER2-positive and triple-negative breast cancer |
| Adjuvant | After surgery: treats microscopic disease left behind | Stage III colon cancer, many breast cancers |
| Perioperative | Both before and after | Gastric cancer chemotherapy |
The other treatments
- Chemotherapy kills dividing cells. Side effects: bone marrow suppression (neutropenic sepsis), mucositis, hair loss, nausea; oxaliplatin causes neuropathy, anthracyclines cardiotoxicity.
- Radiotherapy damages DNA with ionising radiation, given in fractions. Early effects: skin reaction, mucositis, proctitis. Late effects: fibrosis, strictures, poor wound healing, second cancers.
- Targeted therapy blocks a specific molecule: trastuzumab (HER2), cetuximab (EGFR, RAS wild-type colorectal), imatinib (KIT in GIST).
- Immunotherapy releases the immune system’s brakes: anti-PD-1 (pembrolizumab, nivolumab) and anti-CTLA-4 (ipilimumab). Mismatch-repair-deficient tumours respond especially well.
- Hormone therapy: tamoxifen and aromatase inhibitors (breast), androgen deprivation (prostate).
Immunotherapy side effects that reach the surgeon
Immune-related colitis (diarrhoea, pain, even perforation), hepatitis, pancreatitis and adrenal or pituitary failure. Ask every oncology patient with abdominal pain which treatment they are on: the answer may be steroids rather than surgery.
Palliative care
Early involvement of palliative care improves symptoms and quality of life. It is not only for the last days.
Frequently asked questions
What is the difference between neoadjuvant and adjuvant therapy?
Neoadjuvant treatment is given before surgery to shrink the tumour and treat micrometastases early. Adjuvant treatment is given after surgery to treat microscopic disease left behind.
What are the principles of cancer surgery?
Remove the tumour en bloc with a clear (R0) margin, remove its draining lymph nodes, and handle the tumour as little as possible.
What side effects of immunotherapy matter to surgeons?
Immune-related colitis (even perforation), hepatitis, pancreatitis and adrenal or pituitary failure, which can mimic a surgical abdomen.
Further reading
- Temel JS, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med 2010;363:733–42.
- Haanen J, et al. Management of toxicities from immunotherapy: ESMO Clinical Practice Guideline. Ann Oncol 2022;33:1217–38.