Cancer Treatments
Breast Carcinoma and DCIS
CARCINOMA-IN-SITU
Two pre-malignant breast conditions exist; ductal carcinoma-in-situ (DCIS)
and lobular carcinoma-in-situ (LCIS). Diagnosis is made using the state
of the art Mammotome biopsy technique, in a comfortable outpatient setting.
Treatment for DCIS usually involves lumpectomy, tamoxifen (an anti-estrogen
pill) +/- radiation. LCIS may be treated expectantly with careful observation
or with prophylactic mastectomy and immediate reconstruction. Our highly
trained surgeons are expert in interpreting the complexities of these conditions,
and planning appropriate treatment strategies.
BREAST CANCER
Breast cancer treatment has undergone many changes in recent years. Currently,
the emphasis is on breast conservation, and we offer lumpectomy wherever
possible. We recommend breast reconstruction in situations where mastectomy
is necessary. Neoadjuvant (preoperative) chemotherapy is used to facilitate
breast conservation when needed. Our surgeons engage in sophisticated treatment
planning, in all cases. This involves rigorous staging using a combination
of CT, PET, Nuclear Bone Scan, MRI and PET fusion. Our highly trained surgeons
have extensive experience in Sentinel Node Biopsy (SNB), and this is offered
as an alternative to the traditional axillary lymph node dissection, where
indicated.
Colo-rectal Carcinoma
While the true cause of colo-rectal cancer remains unknown, we do know
that most colo-rectal cancers arise in a polyp, and that detection and removal
in the polyp stage is the surest way to prevention. Screening is thus carried
out by fecal occult blood (FOB) testing and colonoscopy, where indicated.
In addition, as we become more aware of the importance of family history
in this condition, people with a strong family history of col-rectal cancer,
especially if diagnosed at a young age (< 40 years), should undergo regular
evaluations. Colorectal cancers are one of the few cancers where a blood
test (serum CEA level) can be used to detect tumor presence. This CEA test
is very useful to test for recurrence of the cancer and is measured regularly
in the follow up of patients where it was raised before tumor removal.
COLON CANCER
Most colon cancers are treated primarily with surgery, which involves
removal of the segment of affected colon with its draining lymph nodes.
Our highly trained surgeons are expert at performing right hemicolectomy,
transverse colectomy, left hemicolectomy or sigmoid colectomy either open
or via laparoscopy, where indicated. Adjuvant (post-operative) chemotherapy
is usually given if the lymph nodes are involved with cancer, and our surgical
oncologists work closely with our colleagues in medical oncology to coordinate
this therapy.
RECTAL CANCER
As initial therapy, most rectal cancer patients receive neo-adjuvant
(pre-operative) chemo-radiation to downstage the tumor. This is then followed
with surgical resection. The emphasis is on sphincter preservation (no colostomy)
wherever possible, and only the very low tumors (those close to the anus)
need a permanent colostomy. Our highly competent surgeons are expert at
performing low anterior resection or abdomino-perineal rectal resection,
using the nerve sparing technique of Total Mesorectal Excision (TME). This
minimizes the postoperative problems of sexual and bladder dysfunction that
were commonly seen in the past in patients undergoing surgery for rectal
cancer.
Esophago-Gastric
Cancers of the upper digestive tract have always posed a difficult treatment
challenge. Some advances in recent years have allowed our highly trained
cancer surgeons to offer hope to patients suffering from these troublesome
tumors.
ESOPHAGEAL CANCER
While the cause is unknown, we do know that gastro-esophageal reflux disease
(GERD) can cause cancer of the lower end of the esophagus, probably from
chronic irritation of the esophageal lining, over a prolonged period of
time. Esophageal cancer has two major types; squamous and adenocarcinoma
(the type that arises from GERD). These cancers usually do not become recognized
until late, when blockage of the esophageal tube occurs. Patients complain
of difficulty in swallowing and regurgitation.
One advance has been neoadjuvant (pre-operative) chemo-radiation. Our
expert surgical oncologists recommend this for most esophageal cancer patients,
to facilitate subsequent surgical removal of the tumor. We believe that
surgery offers the best chance of a cure for esophageal cancer, and thus
we take a very aggressive approach to the disease. Upon completion of pre-operative
therapy, we perform extensive state of the art staging with CT, PET, and
PET fusion studies. We perform a total esophagectomy in most cases, using
the harmonic scalpel, and a meticulous operative technique. In recent years,
we have found the transhiatal approach to be superior. This avoids directly
opening into the chest cavity, and greatly minimizes post-operative pain.
GASTRIC CANCER
Stomach or gastric cancer mainly consists of adenocarcinoma. Patients
with this disease may have a variety of symptoms, ranging from nausea and
vomiting, bleeding from the GI tract, weight loss, and early satiety. The
diagnosis is frequently made, nowadays, by gastroscopy (EGD) performed for
one of these symptoms.
The initial therapy here is usually surgical. We believe that long term
cure can only be achieved by careful surgical technique. In patients being
treated with curative intent, our expert surgical oncologists will perform
a meticulous total or sub-total gastrectomy. A lymph node dissection (lymphadenectomy)
for gastric cancer has been shown to improve survival in certain groups
of patients. Our highly trained surgeons are expert in this technically
challenging procedure and will offer it in indicated patients. Recent research
has shown that post-operative chemo-radiation can improve survival in patients
with gastric cancer, and we recommend this in many instances.
Fistula
As word spread of our experience at managing complex abdominal tumors,
we began to receive referrals of patients with complex fistulas. A GI fistula
is an abnormal tract between a part of the GI tract and either another part
of the GI tract or the skin. Thus, these include entero-cutaneous, esophago-cutaneous,
biliary-cutaneous, colo-cutaneous, and entero-enteral fistulas. These are
difficult management problems and cause great distress in affected patients.
If handled in the proper way, a successful outcome can be reached. If mis-handled,
the situation can be made worse.
TREATMENT
We have extensive expertise in the fistula management, including anatomical
delineation, nutritional support, sepsis control, and complex surgical repair,
at the appropriate time.
Our office is now accepting appointment requests for fistula evaluation.
We also welcome transfers from other surgeons and hospitals, for complex
fistula management.
Lung Cancer
Most forms of lung cancer originate in the bronchi or major airways of
the lungs. There are two major types. Small Cell lung cancer is usually
treated with chemotherapy and radiation only. Non Small cell cancers
can be treated via a combination of surgery and chemo-radiation, depending
on the stage. Non small cell varieties include squamous cell, adenocarcinoma,
and large cell undifferentiated cancer. Lung cancer, especially the
squamous cell variety, is strongly linked to smoking. Lung cancer spreads
by metastasizing to lymph nodes in the chest and by the blood stream to
such sites as brain, bone and liver.
EPIDEMIOLOGY
According to the American Cancer Society, Lung Cancer is currently the
leading cause of cancer death among both men and women; there will be an
estimated 163,510 deaths from lung cancer in 2005, accounting for
around 28% of all cancer deaths. More people die of lung cancer than of
colon, breast, and prostate cancers combined. Most early cancers are found
in patients having routine chest X-rays, either as part of an annual medical
exam or as a preoperative test for surgery. More advanced tumors are picked
up in patients who are symptomatic with chronic cough, coughing up blood,
weight loss, shortness of breath, or unexplained hoarseness. Further staging
with CT scans is then undertaken.
TREATMENT
The treatment for non-small cell lung cancer is surgical removal of the
tumor, if possible, as we believe surgery is the only really curative therapy.
For surgery to be feasible, however, the tumor must be at a fairly early
stage. For this reason we carry out extensive staging tests to make sure
a patient is a good candidate for surgery. These include special breathing
tests to make sure a patient can withstand removal of part or all of a lung.
Our highly trained surgeons are experts at performing lobectomy (removal
of a lobe) or pneumonectomy (removal of a lung), depending on the location
and size of the tumor. At the same time we usually perform a meticulous
lymphadenectomy, or lymph node dissection. This involves removal of lymph
glands form the central part of the chest, near the heart and windpipe.
Surgery is often used in conjunction with a combination of chemotherapy
and radiation. We work closely with our colleagues in medical and radiation
oncology to co-ordinate these treatments.
LUNG METASTASES
Primary cancers from other sites can metastasize to lung. Examples of
these are colorectal, renal cell, sarcoma and melanoma. When the degree
of spread is minimal, they can be surgically treated. Our expert surgeons
are highly proficient at removal of these metastases either via thoracoscopic
(VATS) or open surgery, depending on the size and location of the tumor(s)
in question.
Pancreatic
Pancreatic tumors, the majority of which involve the part of the gland
known as ‘the head”, usually cause the patient to become jaundiced.
Patients with this disease frequently consult their doctor with “yellow
eyes”. Treatment is aimed at making the diagnosis at an early enough
point, before the tumor has had a chance to spread beyond the pancreas.
In these cases, the tumor can be surgically removed, the best hope for a
long-term cure. In resectable cases, a “Whipple” procedure is
performed, which involves removal of the head of the pancreas, the duodenum
and part of the bile duct. Patients can have a good survival expectation
if the disease is diagnosed early enough to allow a Whipple procedure and
there is no residual cancer left behind after the surgery. This is especially
the case if the lymph nodes have been adequately sampled and are clear of
the cancer.
WHIPPLE OPERATION
We believe that surgery is the only effective therapy which can bring
about long-term cure. This usually involves a Whipple procedure. Our highly
trained surgeons are experts at performing this highly specialized and complex
operation. In addition to removing the tumor, we perform a meticulous sampling
of the lymph glands. To ensure patients are good candidates for this procedure,
we perform extensive pre-operative testing to confirm the tumor has not spread,
and that the patient can withstand surgery. This may include CT scans, ERCP
(an endoscopic procedure to obtain a roadmap picture of the bile and pancreatic
ducts), MRI, and cardiac testing to determine the patient’s ability
to undergo a major operation. Occasionally, for larger tumors, preoperative
chemotherapy is recommended. In addition, chemo-radiation may be offered
postoperatively as adjuvant therapy. We work closely with our colleagues
in medical and radiation oncology to co-ordinate these treatments.
RFA/Metastectomy
METASTECTOMY
A metastasis (pl. metastases) is a cancer deposit which has grown at a
remote site from the primary tumor. An example of this is a lung or liver
metastasis from a colon cancer primary. This may develop years after the
original tumor has been treated, and is thought to arise due to the spread
of microscopic cancer cells in the blood stream, until they become lodged
at the remote site. It may take many months or years for these cells to
replicate to the point of forming an actual tumor nodule or deposit, which
can be detected by radiological scans. Historically, the idea of surgically
removing these metastatic lesions was resisted, as it was felt that these
patients should be treated with chemotherapy only, and that surgery did
not help control the disease. Data collected over the years, however, has
suggested that a select group of patients may survive for many years if
these metastases are surgically removed (metastectomy). These patients usually
also receive additional chemotherapy to consolidate this treatment. The
decision to surgically remove metastases from the lung or liver depends
on many factors. These include the number of lesions, their size, and their
exact location.
We currently offer lung and liver metastectomy, where clinically indicated.
In these clinically indicated situations, where the extent of metastatic
disease is limited, we believe that aggressive surgical therapy offers the
best chance for a long-term cure. Our highly trained surgeons are experts
at surgical removal of metastatic lung or liver tumor deposits, using laparoscopy,
thoracoscopy (VATS), or open surgery, as indicated by the location, number
and size of the tumor(s). Surgery is often used in conjunction with chemotherapy
and radiation. We work closely with our colleagues in medical and radiation
oncology to co-ordinate these treatments.
RADIO-FREQUENCY ABLATION (RFA)
Radio-frequency ablation (RFA) is a modality which delivers a high temperature,
via a probe, directly into a tumor nodule. As it employs micro-wave technology,
it effectively “cooks” cancer cells, while having minimal effect
on normal tissue. It is usually reserved for patients who are not candidates
for formal surgical resection of the tumor mass, but may also be used as
an adjunct to formal surgery. Its main use is in metastatic cancer, but it
can also be used for unresectable primary tumors. Because of its low incidence
of side-effects, it is a modality which we are using with increasing frequency,
for those really difficult to reach tumor masses. Our specialty trained surgeons
are highly proficient at its use, delivering the treatment via open surgery,
laparoscopy, or percutaneously under CT guidance, depending on the needs
of the individual patient.
Sarcoma
Soft-tissue sarcoma is a cancer which arises from the connective tissues of
the body. Thus, its behavior is somewhat different to many of the cancers which
we treat. It rarely spreads to lymph glands, but frequently can spread through
the blood stream to remote sites such as lung, liver, or bone. It arises usually
either in an extremity or in the retroperitoneum (tissues at the back of the
abdominal lining, near the kidneys).
TREATMENT
Because sarcomas are relatively resistant to chemotherapy, surgery plays a
very important part in the treatment of sarcoma. Excision of the primary tumor
with a wide margin of normal tissue is of paramount importance. In spite of
this, better insight into the nature of spread and recurrence of this cancer
has allowed us to develop new techniques which make limb preservation a priority.
In combination with either pre or post-operative radiation therapy, good long-term
survival rates can be obtained in the majority of cases. In addition, sarcoma
is one cancer type where brachytherapy can play an important role (this is where
small doses of radiation are delivered directly into the affected tissues via
surgically placed catheters, which are usually removed after a few days).Our
highly trained surgeons are experts in the management of all varieties of soft-tissue
sarcoma, regardless of location.
Because of its unique patterns of spread, lymphadenectomy, or lymph node dissection
is not a standard in the treatment of sarcoma. However, removal of single or
focal metastases from lung or liver, is not infrequently performed, and long-term
disease control can often be obtained in this way.
RETROPERITONEAL SARCOMA
Because of the location of these tumors close to vital structures, such as aorta,
kidneys and pancreas, meticulous surgical technique is of paramount importance.
Radiation therapy plays much less of a role here, as abdominal radiation therapy
is fraught with complications. Our specialized surgeons utilize their expert
training to perform very complex tumor resections in these difficult locations,
with an emphasis on preservation of vital structures.
Sentinel Node Biopsy
The Sentinel Node is considered the first or primary lymph gland to which
cancer cells will spread. The importance of this gland is that if it is removed
and proven to be free of cancer cells, then the primary tumor is much less likely
to have spread, and thus the risk of disease recurrence is very low. Great advances
in the field of sentinel node technology have been achieved in recent years,
in the areas of breast cancer and melanoma. Further research is underway in
other disease sites such as colorectal and lung cancer.
THE PROCEDURE
The procedure involves injecting the primary tumor with a radioactive colloid
in conjunction with a colored dye, on the morning of surgery. These microscopic
particles then migrate within the lymphatic channels, mimicking the migration
of a cancer cell. The first lymph gland they reach is the Sentinel Node. It
is identified by using a gamma probe to find the areas of highest radioactivity,
and then visualization of the injected dye. Removal of the Sentinel node is
carried out by a minimally invasive technique. The node is then subjected to
rigorous histological analysis, including immuno-histochemistry, where indicated,
by our expert pathologists. Our highly trained surgeons have been involved in
this extremely innovative procedure since its inception, and continue to play
a major role in the evolution of this cutting edge technology.
Thyroid
The thyroid gland is located in the neck, and helps regulate the body’s
metabolism. Cancer of the thyroid is rare (less than 2% of all cancers), and
is either differentiated (the majority) or un-differentiated. Risk factors for
thyroid cancer include family history (medullary type) and previous history
of external beam irradiation to the neck. Many of these are initially
picked up as a thyroid nodule.
THYROID NODULES
Thyroid nodules consist of small round lumps within the thyroid
gland. The patient usually feels a swelling in the neck, near the lower part
of the windpipe or trachea, and seeks help. They are managed by initially performing
an ultrasound scan to determine if they are cystic or solid. If cystic (fluid
containing) they can be aspirated with a needle and usually disappear permanently.
If solid, a fine needle aspiration (FNA) cytology is performed for diagnostic
analysis of the cellular material. Only 5-15% of all thyroid nodules turn out
to be malignant. If the FNA demonstrates the nodule to be definitively benign,
it can be left alone and watched. If the FNA is equivocal, the surgeon will
usually recommend removal of the nodule. This is most often achieved by removing
part of that thyroid lobe containing the nodule (sub-total lobectomy). Our
highly trained surgeons are experts at evaluating and surgically treating these
lesions, where indicated.
DIFFERENTIATED THYROID CANCER
Most thyroid cancers are of the so-called differentiated
type. This means that the cancer cells are slow to multiply and still behave
somewhat like normal thyroid cells. For this reason, after surgery, they can
be treated with radio-active iodine, and 10 year survival rates in the order
of 87% can be achieved. Differentiated thyroid cancer can spread to local lymph
glands and occasionally by the blood stream to remote sites. The treatment
consists of total thyroidectomy, with lymphadenectomy if the lymph glands are
involved with cancer. The patient is the subsequently followed with serial radio-active
iodine scans and serum thyroglobulin levels. Recurrences can be treated with
high dose radio-active iodine, with good results. The overerall prognosis for
this disease is good.
Our expert surgical oncologists specialize in the management of thyroid cancer
and are highly proficient in all aspects of thyroid surgery. Modern surgical
techniques are employed to preserve the important recurrent laryngeal nerve
(which controls the voice box) and the parathyroid glands (which regulate calcium
levels in the blood).
UN-DIFFERENTIATED THYROID CANCER
These consist of medullary cancer and the
rarer anaplastic thyroid cancer.
Medullary cancer may be associated with the familial MEN syndrome. Treatment
is total thyroidectomy with central lymphadenectomy. For those relatives of
patients with MEN who have a positive Ret proto oncogene marker on chromosome
10, prophylactic thyroidectomy is performed at an early age. Patients can be
followed with serial blood calcitonin levels.
Anaplastic carcinoma is also undifferentiated, but much more aggressive.
It is not responsive to radio-active iodine and is treated with chemotherapy
and radiation. Surgery has little role to play in the treatment of this condition.
Liver Tumors
These are separated into primary and secondary tumors. Primary liver tumors
arise in the liver itself, while secondary tumors have spread to the liver form
another site.
The main primary liver cancer is hepatocellular cancer (HCC), often associated
with a prior history of hepatitis and cirrhosis. Surgical resection offers the
only real hope of a long-term cure. This involves removal of the part of the
liver containing the tumor. A small percentage of cases may be treated with
liver transplantation, but this depends on the degree of cirrhosis and the size
of the tumor. Thus, removal of part of the liver is the main-stay of therapy.
However, if too much liver is removed, the patient can go into liver failure,
as cirrhotic liver does not regenerate nearly as well as normal liver. Our highly
trained surgeons are experts in evaluating these complex patients. We use state
of the art modern techniques of liver resection to keep intra-operative blood
loss to a minimum. In addition we use radio-frequency ablation (RFA) to compliment
therapy, especially in the case of unresectable lesions.
Secondary liver tumors are metastatic tumors. These most commonly result from
spread of a pre-existing colo-rectal cancer, but can also arise from other primary
sites such as breast, pancreas or kidney. We offer liver resection to patients
who have a limited number of metastatic lesions and where the disease is confined
to the liver. We believe that surgical removal of these metastatic lesions,
in appropriately selected patients, offers the best chance for a long term survival.
Again we employ meticulous techniques to avoid blood loss. Surgery can consist
of a smaller wedge resection or a more extensive lobectomy, depending on the
location and extent of disease. Again, RFA can be used to palliate lesions which
can not be removed.
BILE DUCT TUMORS
Treatment of these tumors depends on the stage of disease. Our highly trained
surgeons perform a full staging evaluation prior to making any decision about
surgery. Treatment of early-stage tumors depends of their location within
the biliary tree. For those high up near the liver we usually perform a formal
liver resection. For tumors in the mid-portion of the bile duct we prefer to
perform a bile duct resection, with subsequent meticulous formation of a bypass
from the bile ducts to the intestine. We perform a Whipple pancreatic resection,
in conjunction with removal of the affected bile ducts, for appropriate tumors
of the lower part of the bile duct.
