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com

Squamous cell carcinoma of

the nasal palate in a dog

Principles of
oncological surgery DUNCAN LASCELLES AND DICK WHITE.

SURGICAL treatment of neoplastic disease is playing an ever-increasing role in the veterinarian's

approach to cancer therapy. In order to carry out successful oncological surgery, surgeons require more
than a comprehensive knowledge of anatomy, physiology, and resection and reconstruction techniques
for the specific area or organ involved. A thorough understanding of general tumour biology, the specific
characteristics of the neoplasm involved, the stage of the disease and thus the prognosis, and the
adjunctive therapies that may be appropriate, is also essential in each case.
Duncan Lascelles
graduated from
FIRST PRINCIPLES OF ONCOLOGICAL * The local and systemic effects of the disease must be Bristol in 1991.
SURGERY assessed. He gained a PhD
in aspects of pre-
* It must be decided whether a cure is possible and, if emptive analgesia in
THE DECISION TO USE SURGERY AND so, whether surgical intervention is indicated. companion animals,
before taking up his
THE ROLE OF SURGERY * The options for alternative treatment must be fully current post of CSTF
Surgery may be used in oncology for a wide variety of assessed in the light of the likely prognosis, as must the resident in small
animal soft tissue
reasons (see box below) but is mainly used to allow a effect of adjunctive therapies combined with surgery. surgery at Cambridge.
diagnosis and for treatment of localised neoplasia. Only when these points have been addressed, can the His particular interests
Before surgery is ever contemplated, a full assessment of most effective surgical approach be defined. lie in oncological and
reconstructive surgery
the situation must be made. Specifically: and the alleviation of
* The type, grade and stage of the cancer must be OPTIMISING THE OUTCOME AT FIRST SURGERY acute and chronic
pain in companion
defined. A surgical procedure may be involved in this When a decision to use surgery has been made, the best animals.
process. possible outcome must be achieved the first time -

Goals of oncological surgery

Prophylactic treatment Diagnosis and staging of Treatment of metastatic

neoplastic disease disease Dick White qualified
from the Royal
Veterinary College,
London, in 1975 and
gained his PhD in
1980. He is lecturer in
Definitive excision Support surgeries small animal soft
tissue surgery at
Cambridge, with
special interests
including oncological,
x ENT, respiratory and
reconstructive
Cytoreduction of the Treatment of oncological surgery. He is a
tumour mass Palliative treatment diplomate of both
emergencies
the American and
European Colleges of
Veterinary Surgeons.

In Practice 0 APRIL 1999 163

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second surgeries are rarely PROPHYLACTIC TREATMENT

successful. The reasons why the
first surgery offers the best A prophylactic oncological surgery can be defined as
chance of a cure are that: one that results in a reduction in either the anticipated
* Untreated tumours tend to incidence rate of a particular tumour type or the rate of
have more normal surrounding recurrence of a neoplastic disease after therapy. Several
anatomy that facilitates surgical examples of prophylactic surgery performed commonly
removal. in small animals are considered below.
* Recurrent tumours may seed
to involve tissue planes previ- MAMMARY TUMOURS IN THE BITCH
ously free of neoplasia, necessi- Ovariohysterectomy performed prior to the first season
tating a wider resection than the is known to reduce the incidence of malignant mammary
initial tumour would have tumours to 0 05 per cent of that which might be expected
required. in intact bitches (and to a lesser degree in cats). This rel-
x. M. The most active and invasive ative risk rises steeply beyond the first oestrus, with the
parts of the tumour are at the incidence for bitches spayed after the second season
edges where the blood supply is being 25 per cent of that expected in intact bitches. By
best; thus subtotal resection may the age of two years, there is little or no cancer-sparing
leave behind the most aggres- effect. Despite the fact that a significant proportion of
2 - sive components of the tumour.
iM Patients with tumour recur-
malignant mammary tumours have oestrogen receptors
and are thought to have hormonally dependent growth,
rence often have less normal there is no benefit to ovariohysterectomy at the time of
.I
1 wtissue available for closure. mastectomy.
Recurrent mast cell tumour
on the flank of a dog PERIOPERATIVE PLANNING
following the use of BENIGN VAGINAL TUMOURS IN THE BITCH
resection margins that were As well as defining the precise role of any surgical pro- Ovariectomy is an effective means of preventing both
too narrow cedure before surgery is undertaken, full consideration the development and recurrence of benign and, possibly,
must be given to the reconstructive aspects if surgery is malignant vaginal tumours in the bitch, and the proce-
to be successful. Tumour resections, particularly those dure should be considered an integral part of the surgical
involving the skin and associated tissues, may result management of this disease along with local excision.
in substantial tissue deficits. Lack of preoperative Malignant vaginal tumours are not as hormonally influ-
consideration of a reconstructive plan, and fear of not enced and a greater proportion of these occur in spayed
being able to close the resulting deficit, are often potent bitches.
deterrents to the first and most important stage of
surgery, namely the excision of the tumour. Ideally, one TESTICULAR TUMOURS IN THE DOG
individual should remove the tumour, adhering to the The incidence of testicular neoplasia is significantly
oncological principles regarding the margins required, greater in the undescended testicle (about 14 times the
and a second individual should then perform the incidence in a normal dog). This means that approxi-
reconstruction. However, this is not feasible in most mately 50 per cent of retained testicles will develop neo-
institutions and practices, and the surgeon must give full plastic lesions. The risk of neoplasia is also greater than
consideration to the reconstruction prior to embarking on normal in the descended testicle in cryptorchid dogs,
the excision. probably due to genetic factors that predispose to the
Preoperative planning of anaesthetic and analgesic development of neoplasia. Sertoli cell tumours and semin-
Mammary carcinoma regimens, as well as postoperative care, including the omas are the most frequent tumour types associated with
in a dog - a tumour that
can be prevented by use of drains, will minimise perioperative morbidity. cryptorchidism, the former representing 60 per cent of
prophylactic surgery
(ovariohysterectomy)

Sertoli cell tumour of the testicle, seen spreading along

the spermatic cord deep into the abdomen. Such tumours of
undescended testicles can be prevented by castration

164 In Practice * APRIL 1999

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cryptorchid tumours. Bilateral elective orchidectomy

obviously prevents the development of such tumours in General principles of biopsy
at-risk patients. Castration of non-cryptorchid dogs, as
well as preventing testicular cancer, will also help to pre- If future treatment of a neoplasm is not to be com-
vent perianal adenomas. promised, a few general principles of biopsy should
be borne in mind:
DERMAL SQUAMOUS CELL CARCINOMA IN * The biopsy site should be positioned within the
THE CAT probable surgical field
Exposure of unpigmented skin to ultraviolet radiation * Specimens should be handled carefully and
can result in the development of squamous cell carcino- multiple samples obtained if possible
ma. Often this is preceded by a pigmented premalignant * Samples should be taken from different areas of
lesion, the removal of which, together with any suscepti- the lesion
ble unpigmented area (eg, resection of the complete * The biopsy should be conducted so as to
pinna and vertical aural canal, or nasal planum amputa- minimise the risk of local dissemination of the neo-
tion), is highly successful in preventing progression to plastic disease. Uninvolved anatomical planes and
squamous cell carcinoma. compartments should not be breached and fresh
instrumentation should be used for each site
COLORECTAL TUMOURS IN THE DOG biopsied
Benign polypoid lesions of the rectum have the potential * Adequate exposure should be achieved for both
to undergo malignant transformation into a carcinoma- incisional and excisional biopsies to ensure there is
tous form. Early wide local resection of these lesions is minimal disruption of the tumour and adjacent
therefore successful in preventing some forms of rectal uninvolved anatomical planes
cancer.

treatment will be dictated by knowledge of the tumour

DIAGNOSIS AND STAGING OF type. For example, certain tumours such as soft tissue
NEOPLASTIC DISEASE sarcomas, oral fibrosarcomas and mast cell tumours have
a high rate of local recurrence and thus require removal
Attaining a diagnosis and the correct staging of a sus- with much wider margins than benign or low-grade
pected neoplasm are of paramount importance before tumours. Permanent local tumour control and survival
any treatment, surgical or otherwise, can be considered. are positively correlated, and preoperative knowledge of
A histopathological diagnosis must be achieved if a the tumour type will help in planning the correct defini-
prognosis is to be established and the most appropriate tive surgery and thus achieving a local cure. In some
surgical procedure or adjunctive therapy instigated. instances, however, the surgical treatment plan will not
Treatment without biopsy information will be at best depend on prior knowledge of the tumour type; for
speculative and can rarely be justified even in the hands example, lobectomy for a solitary lung mass, splenec-
of an experienced oncologist. Imaging (radiography, tomy for localised splenic neoplasia, or surgical excision
ultrasonography, magnetic resonance imaging, computed for mammary neoplasia. Also, if the biopsy is as difficult
tomography or nuclear scintigraphy) and biopsy tech- as the postulated curative surgery, such as is true for the
niques are used in combination to stage the tumour. removal of brain tumours, then information about the
There are a variety of broad categories of biopsy tumour type should be obtained after surgical removal.
technique: In general terms, though, a biopsy should be obtained
* Cytology (fluid and exfoliative cell recovery, fine prior to definitive treatment for most externally accessi-
needle aspirates, impression smears); ble masses, as biopsy information provides the corner- Tumour biopsy is an integral
* Needle core biopsy (using Tru-cut, Menghini or stone for planning the surgical procedure. part of oncological surgery.
Jamshidi type needles); Biopsies should always be
taken from the centre of the
* Incisional biopsy (surgically removed samples, sur- mass

face pinch or punch samples);

* Excisional biopsy (complete post-surgical specimen).
The type of procedure chosen will depend wholly on
the information the clinician requires: if the detection of
individual neoplastic cells is sufficient (eg, for mast cell
tumours) then cytological techniques will suffice; how-
ever, if a stromal tumour is suspected (eg, a sarcoma),
then the tissue architecture will need to be examined and
needle core or incisional biopsy techniques will be
required. Also, if tumours such as mast cell tumours or
squamous cell carcinomas are to be graded, needle core
or incisional techniques are generally required. Often a
relatively non-invasive or simple procedure is used to
start with, and other techniques moved on to as more
information is required, until sufficient is known about
the neoplasm to allow formulation of the most effective
surgical and adjunctive therapy protocol.
Preoperative biopsy is definitely indicated in the
majority of instances, as the type and/or extent of the

In Practice * APRIL 1999 165

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DEFINITIVE EXCISION

Definitive excision refers to the use of surgery as the

sole treatment (ie, without adjunctive radiotherapy or
chemotherapy) to achieve an outright cure. This is possi-
ble for localised and, occasionally, regional neoplastic
disease. The goal is to remove all of the neoplastic tissue
in one surgery - the first surgery. Subsequent surgeries
are greatly complicated by the need to carry out a much
more radical resection in an area where the anatomy is
very possibly distorted and all the tissue exposed at the
previous surgery must be resected. Realistically, the
definitive surgery probably does not remove every last
tumour cell; instead, the animal's own local immune
defence mechanism may well 'mop up' the remaining
neoplastic cells. However, this process should not be
relied upon to correct a compromised surgical technique!
The incision, surgical exposure and surgical margin
are the most important aspects of definitive excision
surgery.

THE INCISION AND SURGICAL EXPOSURE

The site of the incision should take into account the need All oncological surgeries should be planned carefully to
ensure that adequate margins can be achieved and that the
to resect any scars that are a result of previous surgery or area can be reconstructed. In this case, the surgical margins
sites of biopsy. Such scars should be afforded the same for removal of a cutaneous haemangiopericytoma have
been mapped out, as has the thoracodorsal axial pattern
margins as the bulk of the tumour, these margins having flap that will be used for reconstruction
been decided on prior to surgery on the basis of biopsy
information. The incision should also allow adequate
access to the tumour to avoid rough handling and frag- vation of surrounding neuronal tissue.
mentation of the neoplastic tissue. * INDICATIONS for local excision include benign
tumours which show no tendency to local infiltration
THE SURGICAL MARGIN (eg, lipoma, histiocytoma, sebaceous adenoma, thyroid
The choice of the margins at surgery will profoundly adenoma).
affect the success of the surgery as a curative procedure. * CONTRAINDICATIONS include invasive benign tumours
The margin of grossly normal tissue taken with the obvi- and all malignant tumours.
ous 'primary' mass will depend on the histological type
and grade of tumour, again emphasising the need for Wide local excision
appropriate preoperative biopsy techniques. The appar- When a significant predetermined margin of surrounding
ently normal tissue surrounding malignant tumours is tissue is removed together with the primary mass, the
frequently infiltrated by neoplastic cells and, in general excision is termed 'wide local excision'. Again, preoper-
terms, the greater the likelihood of local infiltration the ative knowledge of the tumour type and grade, obtained
wider the surgical margins must be. Thus, although after appropriate biopsy, is essential in deciding on an
margins are usually described in terms of a specified appropriate margin. An intermediate-grade mast cell
distance, every consideration should be given to the tumour of the skin will dictate a margin of 3 to 4 cm on
biological behaviour of the tumour in question. It is also all boundaries, whereas a well differentiated dermal
worth remembering that the most effective natural barri- squamous cell carcinoma will only require a margin of
ers to the spread of cancer are collagen-rich, relatively I cm on all boundaries. Anatomical considerations may
avascular tissues including fascia, tendons, ligaments dictate whether it is possible to resect the mass with the
and cartilage. Fat, subcutaneous tissue, muscle and other appropriate margin, and consideration should be given to
parenchymatous organs offer relatively little resistance the use of appropriate adjunctive therapy. Very often,
to the spread of invading neoplastic cells. especially on the limbs, the appropriate depth of surgical
Depending on the extent of the margins, the surgical margin cannot be obtained without severely compromis-
procedure can be categorised anatomically as local exci- ing function, and in these circumstances resection of a
sion, wide local excision or radical local excision. carcinoma or mastocytoma should go as deep as a
grossly clean fascial plane. A collagen-rich fascial plane
Local excision (eg, a muscle sheath) that may act as a natural boundary
Local excision denotes the removal of a neoplastic mass should be removed, as tumour cells will be infiltrating
with the minimal amount of surrounding normal tissue. the surface.
This often means removal of a tumour through its natural * INDICATIONS for wide local excision include benign
capsule or immediate boundaries. Although an additional tumours with local infiltration (infiltrating lipoma) and
margin of normal tissue is usually removed, there are malignant tumours with limited infiltrative potential
some instances where it is desirable not to exceed the (eg, well differentiated squamous cell carcinoma, low-
boundary of the tumour so as to preserve vital surround- and intermediate-grade mast cell tumours).
ing tissue; for example, removal of feline thyroid * CONTRAINDICATIONS include malignant tumours with
tumours with preservation of the parathyroid tissue, or considerable potential for local infiltration (eg, sarco-
removal of central nervous system tumours with preser- mas).

166 In Practice a APRIL 1999

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(left) Compartmental resection of an intramuscular sarcoma.

(above) Resected sarcoma showing normal muscle tissue on
all sides of the tumour. This grossly normal tissue should be
submitted for histopathological examination to determine
whether or not a complete resection has been carried out

Radical local excision attachments for treatment of mandibular chondrosarco-

Removal of a tumour with anatomically extensive mas or osteosarcomas; excision of the eyelids and orbital
margins of tissue extending into fascial planes which are contents tor removal of invasive squamous cell carcino-
undisturbed by the primary growth of the tumour is mas of the eyelid; and radical chest wall resection or
termed 'radical local excision' or 'compartmental' exci- abdominal wall resection for the removal of sarcomas.
sion. Sarcomas, in particular, extend along fascial planes Amputation is also a form of radical local excision,
rather than through them, and this pattern of growth indicated when a suitable compartmental or muscle
dictates removal of the entire anatomical compartment group excision is not achievable without seriously
rather than simply wide margins of tissue. One example impairing limb function (eg, limb amputation for digital
of such surgery is the resection of a single muscle group squamous cell carcinoma or limb osteosarcoma).
for small tumllours involving muscle bellies where the
outer fascial planes have not been breached. In other cir- OTHER PRACTICAL CONSIDERATIONS
cumstances, the area should be resected back to clean Other practical considerations when undertaking defini-
Resection of an abdominal
fascial planes on all sides with removal of all blood ves- tive excisional surgery are the: body wall sarcoma in a cat,
sels, nerves and lymphatics which lie within the affected * Dissection technique; showing (A) the wide
* Reduction of tumour cell contamination within the margins of excision,
compartment. In the limbs, muscles with their associated (B) removal of most of the
fascial capsules comprise individual compartments. surgical field; abdominal body wall and
Other examples of compartmental excision are the * Avoidance of wound complications; (C) reconstruction of the
resulting deficit using a
removal of the whole pinna and vertical ear canal for * Vascular occlusion techniques; polypropylene mesh. Such
resection of squamous cell carcinoma of the pinna; * Management of local lymph nodes; reconstructive procedures
must be fully planned
resection of the complete mandible and its muscle * Reconstruction of the resulting deficit. prior to embarking on
the excisional surgery, or
the surgery will be
compromised

In Practice 0 APRIL 1999 169

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mp,.Wu-- -: gehinsral gld-eIhMn

The patient should be widely clipped to tor, but oncology patients often have one or whole of the operative period, which may
enable effective surgical preparation of a more of the factors that are associated with mean repeat dosing (ie, every three hours
wide area around the proposed surgical site an increased likelihood of postoperative during surgery). The aminoglycoside and
and also to allow for any changes to the infection - namely, old age, poor nutritional quinolone (eg, enrofloxacin) antibiotics,
surgical plan that may be required. Gentle status, obesity, diabetes or other concurrent conversely, require a high peak concentra-
cleaning using effective skin preparations disease, hypoxaemia, the presence of tion of the drug, which determines bacterial
(eg, a chlorhexidine/alcohol mixture) is suf- remote infection, corticosteroid therapy, killing, and then a period of low concentra-
ficent; inideed, vigorous scrubbing of skin immunocompromise, bowel obstruction, tion to re-establish organism sensitivity; thus,
overlying tumours has been associated with thrombocytopenia and/or a poor blood the goal in surgical prophylaxis is for the
an increased rate of metastasis in laboratory supply to the surgical field. Maximising the organisms in the surgical field to encounter
mice. Similarly, vigorous palpation of chances of a successful surgery therefore just one large dose of the aminoglycoside or
tumours prior to surgery should be-avoided, depends on careful planning for pharmaco- quinolone during the operative period.
as damage to the surface of tumours, logical prevention or treatment of infection. The timing of antibiotic prophylaxis is
especially intra-abdominal tumours, may Different classes of antibiotics kill organ- crucial. If preoperative antibiotic therapy is
potentiate seeding of neoplastic cells or isms in very different ways and the initiated too early or continued for too long
rupture and haemorrhage. appropriate dose schedules vary greatly. For postoperatively, increased rates of infection
Infection rates following oncological example, the flactams and clavulanic acid- are observed. The best results are seen
surgery have been shown to be significantly potentiated amoxycillin exhibit time- when antibiotic therapy begins not more
higher than for other surgical procedures, dependent killing and should be dosed to than two hours before the surgical proce-
both in the veterinary and human field. The maintain concentrations of more than the dure and continues for no longer than 24
presence of cancer is not, in itself, a risk fac- minimal inhibitory concentration for the hours post-surgery.

Dissection technique tumour cells appear to adhere to normal tissue via specif-
A scalpel is recommended for making the skin incision ic cell surface receptors, and routine wound or cavity
and any incisions into hollow viscera as it is the least lavage post-removal is of little benefit in terms of 'wash-
traumatic form of tissue separation. Scissors and swabs ing out' remaining tumour cells. However, remaining
should be used for separation of fascial planes and adhe- tumour cells are not likely to be spread by lavage, and
sions, and in body cavities where use of a scalpel may be thus lavage is recommended to effect the removal of
dangerous. Blood vessels should be identified and ligat- blood clots, foreign material, necrotic tissue fragments
ed or cauterised prior to transection, and tissues should and, possibly, any unattached tumour cells. Gloves,
be placed under moderate tension as the dissection is instruments and drapes should be changed after tumour
carried out to facilitate the identification of fascial planes excision and lavage, as tumour cells will adhere to these
and tumour margins. inanimate objects and potentially be seeded to tissues as
closure is carried out.
Reduction of tumour cell contamination within
the surgical field Avoidance of wound complications
There are many reports in the medical literature of tumour Local cellular defence mechanisms may well be very
seeding after biopsy or surgical procedures, and a few vet- important in the removal of remaining tumour cells. The
erinary cases of surgically induced tumour seeding have development of haematomas, seromas and sepsis will all
been identified. The pseudocapsule surrounding many interfere with these defence mechanisms and should be
tumours, especially sarcomas, has viable tumour cells on avoided by meticulous haemostasis, effective closure of
its surface; hence manipulation and surgical exposure of dead space and appropriate use of drains and periopera-
the pseudocapsule can promote tumour spread via exfoli- tive antibiotics.
ated cells. Although it is tempting to grasp tumours using
traumatic tissue forceps, this may lead to tissue fragmenta- Vascular occlusion techniques
tion and dissemination of neoplastic cells. Stay sutures Vascular supply to the tumour, and venous and lymphat-
placed in solid neoplastic tissue or, preferably, in normal ic drainage from it, should be ligated as early as possible
surrounding tissue that is being resected, are the best way during surgery, especially for tumours of ectodermal
of manipulating the tumour. In body cavities, neoplasms origin (eg, squamous cell carcinomas and mast cell
should be isolated from surrounding viscera by large tumours) where the probability of tumour cell exfoliation
laparotomy pads to minimise contamination of normal is high. The benefits of temporary occlusion of the vas-
tissue by exfoliated tumour cells. cular supply to an area that includes the tumour to be
It is often helpful to approach tumours as if they were resected remain unproven.
abscesses or infected tissue, since the techniques and
precautions used to prevent spread of bacteria will also Management of local lymph nodes
help to minimise the spread of neoplastic cells. The practice of routinely removing regional lymph nodes
However, there are some differences. First, with respect in order to prophylactically excise micrometastatic
to adhesions between neoplastic tissue and adjacent deposits is a matter of considerable controversy. Lymph
structures, these represent direct tumour invasion in up nodes are only minimally effective barriers to the pas-
to 57 per cent of cases (Nogueras and Jagelman 1993); sage of tumour cells, and their function is probably one
whenever possible, therefore, the tumour and the of immunological surveillance rather than infiltration of
adhesions should be removed en bloc. Secondly, seeded tumour cells. The immunological response of regional

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lymph nodes appears only to be effective early on in the and surgical margins dictate its removal (eg, inguinal
course of disease. Local lymph node metastasis is com- lymph node removal during mastectomy).
mon for malignant melanomas and most carcinomas,
intermediate for sarcomas, respiratory tumours, cuta- Reconstruction of the resulting deficit
neous carcinomas and mast cell tumours, and rare for There is often a great temptation to compromise excision
nervous system tumours, skeletal tumours, nasal tumours margins through a lack of confidence in one's ability to
and endocrine tumours. However, removing the lymph reconstruct the resulting deficit. However, compromising
nodes may interfere with local immune defence mecha- the surgical margins may result in failure of a single surgi-
nisms in the postoperative period. Another disadvantage cal procedure that could have produced a cure and, poten-
associated with their removal is the potential increase in tially, in the death of an animal that should have been cured.
patient morbidity related to a more extensive surgical It is the resection of tumours involving the skin and
procedure. associated structures that often results in substantial
Decisions must be made on a case-by-case basis, but deficits, and a variety of techniques are available to deal
current general recommendations are: with these deficits (see box below, and also Anderson
* Non-destructive biopsy of grossly normal local lymph 1997). The oncological surgeon should be familiar with
nodes. all of these techniques. It must be stressed that a suitable
i Lymph node removal when the node: closure technique should be planned prior to resection of
- is histologically proven to contain tumour cells; the tumour and that, should the resection have to be
- appears grossly abnormal at surgery; more radical than originally planned, suitable altema-
- is intimately associated with the tissue being removed tives for closure should have been considered.

0 00--0tschulq...t-0H j;:

In Practice 0 APRIL 1999 171

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PALLIATIVE TREATMENT

As far as we know, animals have no comprehension of

the expected future. Therefore, it is perfectly reasonable
to perform a procedure that markedly improves an ani-
mal's quality of life, by providing pain relief or relieving
poor function, despite the presence of unresolved sys-
temic neoplastic disease. In palliative surgery, the over-
riding consideration should be the quality, and not the
quantity, of life that is expected. There are many situa-
tions where comparatively simple surgical procedures
provide a patient with a worthwhile improvement in its
quality of life despite a possibly hopeless long-term
prognosis. Examples of this include limb amputation for
osteosarcoma causing lameness, splenectomy for a
bleeding haemangiosarcoma, oral resection for a
malignant melanoma causing dysphagia, tracheostoma
for laryngeal malignancy, and removal of large
ulcerated painful mammary carcinomas. The risk versus
lntraoperative radiotherapy
following cytoreductive benefit must always be considered and patients selected
surgery on a bladder carefully.
transitional cell carcinoma.
Perspex is used as 'build-up'
to ensure that the correct
dose of radiation is TREATMENT OF ONCOLOGICAL
delivered to the bladder
wall EMERGENCIES

Surgical emergencies - in particular, pericardial effusion

and tamponade, respiratory distress, abdominal haemor-
CYTOREDUCTION OF THE TUMOUR MASS rhage and urogenital or gastrointestinal obstruction or
perforation - are relatively common in small animal
In some circumstances, definitive excisional curative cancer patients. These patients usually require emer-
surgery for solid tumours is not possible. The need to gency stabilisation, after which the ethical question of
preserve vital structures (eg, central nervous system, whether surgical intervention is right and necessary must
bladder, nasal sinuses) often precludes complete be addressed.
excision. Also, a second attempt at complete surgical
excision of a tumour may be difficult due to distorted
anatomy or lack of resectable tissue. Certain tumour
types (eg, sarcomas) or biological grades of tumour are
associated with very significant rates of local recurrence
even after radical surgery, and resection of such tumours
should always be regarded as incomplete.
'Cytoreductive' surgery (reducing the number of
tumour cells present) in such circumstances should not
be viewed as failed surgery. Such surgery is combined
with other treatment modalities such as local or systemic
chemotherapy, radiotherapy or hyperthermia to try to
achieve a cure, and improves the efficiency of these
adjunctive therapies by reducing the numbers of malig-
nant cells to be treated. Such multimodal therapy is the
optimal form of treatment for sarcomas; for example, a
combination of mandibulectomy, radiotherapy and sys-
temic cisplatin chemotherapy is used in the treatment of
mandibular osteosarcomas.
Adjunctive therapies such as chemotherapy or radia-
tion therapy are usually used postoperatively when they
are more effective due to the small numbers of tumour
cells to be sterilised. Radiation therapy can also be used
intraoperatively, but post-removal of the tumour, to
allow close access to the affected area in cases where
there would be a risk of damaging surrounding vital
structures if postoperative radiation therapy were used; a
good example of this is intraoperative radiation therapy
for bladder carcinomas. If adjunctive therapies are used Limb amputation for osteosarcoma must be considered a
preoperatively, then the surgical resection should be palliative surgery - it does not alter the course of the
disease but it does remove an extremely painful lesion
planned to remove all neoplastic cells (ie, to be defini- and gives the dog a good quality of life for the remaining
tive excisional surgery). months

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Examples of radiation-
I__ [induced necrosis following
radiotherapy for an
Removal of a splenic haemangiosarcoma is often carried out intranasal tumour (left) and a
as an emergency procedure maxillary carcinoma (below).
Surgical management is
_required to deal with such
complications
Immediate surgery may be indicated in some cases
but must be followed by appropriate postoperative care.
Very often such surgeries are palliative only; for exam-
ple, resection of bleeding splenic haemangiosarcomas,
primary hepatic carcinomas or metastatic hepatic
neoplasias, resection of ulcerated or obstructive gastro-
intestinal neoplasms that have already metastasised, or
the placement of a permanent cystostomy catheter obvi-
ating the need for immediate euthanasia in animals with
advanced urethral or bladder cancer. Another surgical
procedure that falls into this category is emergency
tracheostomy for immediate palliation of life-threatening
upper respiratory tract obstruction, prior to full evalua-
tion of the extent of the obstructive mass and possible
definitive or palliative excision.

SUPPORT SURGERIES

Support surgeries include the implantation of various

means of providing nutritional support (eg, pharyngos-
tomy tubes, gastrostomy tubes, enterostomy tubes), as
well as long-term central catheters for repeated adminis-
tration of chemotherapeutic agents or of anaesthetic
agents for hyperfractionated radiotherapy regimens (eg,
radiotherapy two or three times a week). They also
include the placement of cystostomy tubes for temporary
urinary diversion while local radiation treatment of ure-
thral tumours is carried out.

The implantation of a
gastrostomy tube is an
example of a support
surgery

In Practice K APRIL 1999 173

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P@stliVlvPe care: general guldeIl.us

Specific anticancer treatments such as surgi- operatively with effective doses of multiple blocks or as part of an epidural. When
cal resection will often very effectively elim- classes of analgesics (eg, an opioid and a carrying out local infiltration, care must be
inate or reduce the incidence and severity non-steroidal anti-inflammatory drug exercised so as not to distort tissue architec-
of pain associated with neoplastic disease. lNSAIDI). If elective surgery for a painful ture and normal fascial planes in the area of
However, the surgery is often complex and neoplastic lesion is planned, it is probably surgery.
can involve extensive skin reconstruction beneficial to provide effective analgesic Appropriate monitoring of cardiopul-
procedures; hence, effective analgesia must therapy for several days prior to surgical monary parameters and major organ func-
be provided in such patients if the sec- intervention in order to minimise central tion is required in the postoperative period
ondary adverse effects of postoperative sensitisation. This could easily be provided to detect any potentially life-threatening
pain, such as increased levels of catabolic with NSAID therapy. The more extensive the complications. Particularly important in this
hormones, prolonged recovery, and planned surgery, the higher the doses of respect is the provision of effective fluid
increased skeletal and smooth muscle tone, opioids (eg, buprenorphine or morphine) therapy in the immediate postoperative
as well as the suffering caused by the pain that should be used. Pre- (where licensed) period and the instigation of oral or enteral
itself, are to be avoided. or postoperative NSAID therapy should be nutrition. These measures are all the more
In line with current thinking, the preven- used, as should local anaesthetics, if possi- important in the many oncological patients
tion of postoperative pain should start pre- ble, either as local infiltration, regional which are relatively old.

TREATMENT OF METASTATIC DISEASE found in particular margins, further surgery or adjunctive

therapy such as radiotherapy can be optimally planned.
Surgical resection of metastatic disease (pulmonary The painting of margins of a resected mass with India
metastases) has been successful in a proportion of ink is particularly useful if there are areas that the sur-
patients. The careful selection of potential patients is geon is suspicious of as being 'dirty', in order that these
important, the basic recommended criteria being: can be accurately assessed by the pathologist. Such
* the primary tumour must be low grade; follow-up of cases is a time-consuming, but essential,
* the patient must have had a prolonged disease-free part of oncological surgery.
interval (at least 300 days);
* the patient must have fewer than three metastatic nod-
ules and a long tumour doubling time (over 40 days). SUMMARY
If such surgery is to be contemplated, the intent
should be cure. Surgery will play a role at one point or another in
the management of most cancer patients. Indeed, the
use of surgery to completely remove localised Reference
FINAL CONSIDERATIONS cancer cures more patients than any other form of NOGUERAS, J. J. & JAGELMAN,
cancer therapy. Compared to other treatment D. G. (1993) Principles of
surgical resection: Influence of
All tissues resected at surgery must be submitted for modalities, surgery of localised tumours effects an surgical technique on treatment
histopathological analysis for evaluation of the surgical immediate cure, is not carcinogenic or immuno- outcome. Colorectal cancer.
Surgery Clinics of North
margins, the mitotic index, any vascular or lymphatic suppressive, and does not have local toxic effects. America 73, 103-116
invasion and the grade or degree of differentiation of the With sensible and appropriate anaesthetic and analgesic
Further reading
tumour. Such information is used to provide the owner protocols and adherence to the principles of oncological ANDERSON, D. (1997) Practical
with the maximum possible detail regarding the progno- surgery, any morbidity associated with anaesthesia and approach to reconstruction
sis. Margins should be tagged or painted with India ink surgery can be minimised and a successful outcome of wounds in small animal
practice. Parts 1 and 2.
immediately after surgery so that, if tumour cells are realised. In Practice 19, 463-471, 537-545

o S
AS a a

In Practice 0 APRIL 1999 175

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Principles of oncological surgery

Duncan Lascelles and Dick White

In Practice 1999 21: 163-175

doi: 10.1136/inpract.21.4.163

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