Removing the Taboo on the Surgical Violation (Cut-Through) of Cancer

Abstract

S urgical training has traditionally incorporated timehonored rules that are fundamental in providing bestpractice approaches in oncology. Of utmost importance is the goal of completely removing the cancer because positive margins of surgical resection contribute to increased local recurrence and decreased survival rates.1 Also, emphasis is given to the careful handling of the cancerous lesions and the surrounding tissues, primarily to minimize dispersion of cancer cells. However, what has come under recent scrutiny is the longstanding dictum not to surgically violate visible tumor during the extirpative process. It has been taught that cutting through gross tumor during an operation increases the risk of spreading viable cancer cells beyond the tumor and into the surrounding normal tissue. Such a maneuver may cause cancer cells to adhere to surgical instruments and subsequently become inadvertently implanted into the surrounding tissue by means of direct contact of the contaminated object. While documentation of this phenomenon is not prominent in the literature, in the head and neck literature a case report alludes to surgical implantationrelated chest wall tumor following pectoralis major flap reconstruction for a pharyngeal cancer defect. 2 Presumably, tumor cells can be seeded by contaminated instruments used in the extirpative process within the adjacent donor site created to reconstruct a defect following cancer resection. Such events, albeit anecdotal, underscore the importance of the concept for en bloc resection, which for more than a century has remained a widely accepted principle in surgical oncology. Although the principle of en bloc resection remains important, its application for surgical extirpation of cancer within some sites of the head and neck is not always feasible. For example, within the nasopharynx, anterior and lateral skull base, and sinonasal region, surgeons often find it difficult to adhere to this rule. Knowing that the fundamental premise is to remove the tumor with clear margins, head and neck surgeons have traditionally strived to achieve such resections for removing tumors as single intact specimens. However, too often the pathologist receives specimens that have been removed in multiple pieces. With some reservations, it is likely that such experiences have led to the acceptance of piecemeal removal of cancer in select situations when monobloc resection is not feasible or practical and as long as complete resection is achieved with clear margins.Exactly when the attitude of accepting piecemeal removal of cancer began remains unclear. The evidence points to a gradual evolution. The early examples of tumor cut-through evolved under circumstances that were more subtle. For example, the surgical technique of Mohs for cutaneous malignant neoplasms has been practiced by dermatologists for more than half a century. In principle, this technique involves serial excisions parallel to the tumor margins until there is clearance of cancer cells. Although the intent is not to deliberately c...

Surgical Management of Sinonasal Cancers: A Comprehensive Review

“…Piecemeal resection, however, makes histological analysis of the margins, and communication with pathologists, more complex [41]. Interestingly, a similar evolution has been observed in laryngeal cancer surgery, with the conclusion that transoral endoscopic laser laryngeal surgery with fragmented tumor excision was relevant from an oncological point of view [40,41]. Under these conditions, endoscopic surgery does not appear to be associated with a significant difference in terms of surgical margins [44][45][46][47].…”

“…Indeed, it has been shown that the prognosis of patients who underwent initial surgery with incomplete partial resection was worse than that of patients who underwent immediate complete surgery [43]. Piecemeal resection, however, makes histological analysis of the margins, and communication with pathologists, more complex [41]. Interestingly, a similar evolution has been observed in laryngeal cancer surgery, with the conclusion that transoral endoscopic laser laryngeal surgery with fragmented tumor excision was relevant from an oncological point of view [40,41].…”

“…It was generally accepted in oncological surgery that tumor resection should be done en bloc and that tumor fragmentation should be avoided at all costs [40]. However, in the case of sinonasal cancers, the confinement of the tumor and the proximity of many important structures make the en bloc resection complex, and excessive resections of healthy tissue are entailed [41]. It should be noted that this problem was already present in open surgeries [7].…”

Endonasal endoscopic surgery for sinonasal squamous cell carcinoma from an oncological perspective

“…The traditional concept of en bloc resection and a wide surgical margin for SN-SCC could lead to an excessively wide resection [19] . For example, in cancers originating from the ethmoid sinus and in contact with the anterior skull base, there is a trend to choose anterior skull base resection to remove cancer in an en bloc fashion and to ensure a wide surgical margin.…”

Endoscopic Versus Open Resection of Non‐Squamous Cell Carcinoma Sinonasal Malignancies

“…Historically, the surgical treatment of sinonasal cancer involved piecemeal resection characterized by high rates of recurrence . Current practices involve either monobloc or piecemeal resection . While surgical therapy has remained the mainstay of curative treatment, approaches to the nasal cavity and paranasal sinuses have evolved significantly .…”