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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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2 -
Recurrent mast cell tumour
on the flank of a dog
following the use of
resection margins that were
too narrow
Mammary carcinoma
in a dog - a tumour that
can be prevented by
prophylactic surgery
(ovariohysterectomy)
second surgeries are rarely
successful. The reasons why the
first surgery offers the best
chance of a cure are that:
* Untreated tumours tend to
have more normal surrounding
anatomy that facilitates surgical
removal.
* Recurrent tumours may seed
to involve tissue planes previ-
ously free of neoplasia, necessi-
tating a wider resection than the
initial tumour would have
required.
x. M. The most active and invasive
parts of the tumour are at the
edges where the blood supply is
best; thus subtotal resection may
leave behind the most aggres-
sive components of the tumour.
iM Patients with tumour recur-
rence often have less normal
.I
1 wtissue available for closure.
PERIOPERATIVE PLANNING
As well as defining the precise role of any surgical pro-
cedure before surgery is undertaken, full consideration
must be given to the reconstructive aspects if surgery is
to be successful. Tumour resections, particularly those
involving the skin and associated tissues, may result
in substantial tissue deficits. Lack of preoperative
consideration of a reconstructive plan, and fear of not
being able to close the resulting deficit, are often potent
deterrents to the first and most important stage of
surgery, namely the excision of the tumour. Ideally, one
individual should remove the tumour, adhering to the
oncological principles regarding the margins required,
and a second individual should then perform the
reconstruction. However, this is not feasible in most
institutions and practices, and the surgeon must give full
consideration to the reconstruction prior to embarking on
the excision.
Preoperative planning of anaesthetic and analgesic
regimens, as well as postoperative care, including the
use of drains, will minimise perioperative morbidity.
164
PROPHYLACTIC TREATMENT
A prophylactic oncological surgery can be defined as
one that results in a reduction in either the anticipated
incidence rate of a particular tumour type or the rate of
recurrence of a neoplastic disease after therapy. Several
examples of prophylactic surgery performed commonly
in small animals are considered below.
MAMMARY TUMOURS IN THE BITCH
Ovariohysterectomy performed prior to the first season
is known to reduce the incidence of malignant mammary
tumours to 0 05 per cent of that which might be expected
in intact bitches (and to a lesser degree in cats). This rel-
ative risk rises steeply beyond the first oestrus, with the
incidence for bitches spayed after the second season
being 25 per cent of that expected in intact bitches. By
the age of two years, there is little or no cancer-sparing
effect. Despite the fact that a significant proportion of
malignant mammary tumours have oestrogen receptors
and are thought to have hormonally dependent growth,
there is no benefit to ovariohysterectomy at the time of
mastectomy.
BENIGN VAGINAL TUMOURS IN THE BITCH
Ovariectomy is an effective means of preventing both
the development and recurrence of benign and, possibly,
malignant vaginal tumours in the bitch, and the proce-
dure should be considered an integral part of the surgical
management of this disease along with local excision.
Malignant vaginal tumours are not as hormonally influ-
enced and a greater proportion of these occur in spayed
bitches.
TESTICULAR TUMOURS IN THE DOG
The incidence of testicular neoplasia is significantly
greater in the undescended testicle (about 14 times the
incidence in a normal dog). This means that approxi-
mately 50 per cent of retained testicles will develop neo-
plastic lesions. The risk of neoplasia is also greater than
normal in the descended testicle in cryptorchid dogs,
probably due to genetic factors that predispose to the
development of neoplasia. Sertoli cell tumours and semin-
omas are the most frequent tumour types associated with
cryptorchidism, the former representing 60 per cent of
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
In Practice * APRIL 1999
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cryptorchid tumours. Bilateral elective orchidectomy
obviously prevents the development of such tumours in
at-risk patients. Castration of non-cryptorchid dogs, as
well as preventing testicular cancer, will also help to pre-
vent perianal adenomas.
DERMAL SQUAMOUS CELL CARCINOMA IN
THE CAT
Exposure of unpigmented skin to ultraviolet radiation
can result in the development of squamous cell carcino-
ma. Often this is preceded by a pigmented premalignant
lesion, the removal of which, together with any suscepti-
ble unpigmented area (eg, resection of the complete
pinna and vertical aural canal, or nasal planum amputa-
tion), is highly successful in preventing progression to
squamous cell carcinoma.
COLORECTAL TUMOURS IN THE DOG
Benign polypoid lesions of the rectum have the potential
to undergo malignant transformation into a carcinoma-
tous form. Early wide local resection of these lesions is
therefore successful in preventing some forms of rectal
cancer.
DIAGNOSIS AND STAGING OF
NEOPLASTIC DISEASE
Attaining a diagnosis and the correct staging of a sus-
pected neoplasm are of paramount importance before
any treatment, surgical or otherwise, can be considered.
A histopathological diagnosis must be achieved if a
prognosis is to be established and the most appropriate
surgical procedure or adjunctive therapy instigated.
Treatment without biopsy information will be at best
speculative and can rarely be justified even in the hands
of an experienced oncologist. Imaging (radiography,
ultrasonography, magnetic resonance imaging, computed
tomography or nuclear scintigraphy) and biopsy tech-
niques are used in combination to stage the tumour.
There are a variety of broad categories of biopsy
technique:
* Cytology (fluid and exfoliative cell recovery, fine
needle aspirates, impression smears);
* Needle core biopsy (using Tru-cut, Menghini or
Jamshidi type needles);
* Incisional biopsy (surgically removed samples, sur-
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
General principles of biopsy
If future treatment of a neoplasm is not to be com-
promised, a few general principles of biopsy should
be borne in mind:
* The biopsy site should be positioned within the
probable surgical field
* Specimens should be handled carefully and
multiple samples obtained if possible
* Samples should be taken from different areas of
the lesion
* The biopsy should be conducted so as to
minimise the risk of local dissemination of the neo-
plastic disease. Uninvolved anatomical planes and
compartments should not be breached and fresh
instrumentation should be used for each site
biopsied
* Adequate exposure should be achieved for both
incisional and excisional biopsies to ensure there is
minimal disruption of the tumour and adjacent
uninvolved anatomical planes
treatment will be dictated by knowledge of the tumour
type. For example, certain tumours such as soft tissue
sarcomas, oral fibrosarcomas and mast cell tumours have
a high rate of local recurrence and thus require removal
with much wider margins than benign or low-grade
tumours. Permanent local tumour control and survival
are positively correlated, and preoperative knowledge of
the tumour type will help in planning the correct defini-
tive surgery and thus achieving a local cure. In some
instances, however, the surgical treatment plan will not
depend on prior knowledge of the tumour type; for
example, lobectomy for a solitary lung mass, splenec-
tomy for localised splenic neoplasia, or surgical excision
for mammary neoplasia. Also, if the biopsy is as difficult
as the postulated curative surgery, such as is true for the
removal of brain tumours, then information about the
tumour type should be obtained after surgical removal.
In general terms, though, a biopsy should be obtained
prior to definitive treatment for most externally accessi-
ble masses, as biopsy information provides the corner- Tumour biopsy is an integral
stone for planning the surgical procedure. part of oncological surgery.
Biopsies should always be
taken from the centre of the
mass
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
to resect any scars that are a result of previous surgery or
sites of biopsy. Such scars should be afforded the same
margins as the bulk of the tumour, these margins having
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-
mentation of the neoplastic tissue.
THE SURGICAL MARGIN
The choice of the margins at surgery will profoundly
affect the success of the surgery as a curative procedure.
The margin of grossly normal tissue taken with the obvi-
ous 'primary' mass will depend on the histological type
and grade of tumour, again emphasising the need for
appropriate preoperative biopsy techniques. The appar-
ently normal tissue surrounding malignant tumours is
frequently infiltrated by neoplastic cells and, in general
terms, the greater the likelihood of local infiltration the
wider the surgical margins must be. Thus, although
margins are usually described in terms of a specified
distance, every consideration should be given to the
biological behaviour of the tumour in question. It is also
worth remembering that the most effective natural barri-
ers to the spread of cancer are collagen-rich, relatively
avascular tissues including fascia, tendons, ligaments
and cartilage. Fat, subcutaneous tissue, muscle and other
parenchymatous organs offer relatively little resistance
to the spread of invading neoplastic cells.
Depending on the extent of the margins, the surgical
procedure can be categorised anatomically as local exci-
sion, wide local excision or radical local excision.
Local excision
Local excision denotes the removal of a neoplastic mass
with the minimal amount of surrounding normal tissue.
This often means removal of a tumour through its natural
capsule or immediate boundaries. Although an additional
margin of normal tissue is usually removed, there are
some instances where it is desirable not to exceed the
boundary of the tumour so as to preserve vital surround-
ing tissue; for example, removal of feline thyroid
tumours with preservation of the parathyroid tissue, or
removal of central nervous system tumours with preser-
166
All oncological surgeries should be planned carefully to
ensure that adequate margins can be achieved and that the
area can be reconstructed. In this case, the surgical margins
for removal of a cutaneous haemangiopericytoma have
been mapped out, as has the thoracodorsal axial pattern
flap that will be used for reconstruction
vation of surrounding neuronal tissue.
* INDICATIONS for local excision include benign
tumours which show no tendency to local infiltration
(eg, lipoma, histiocytoma, sebaceous adenoma, thyroid
adenoma).
* CONTRAINDICATIONS include invasive benign tumours
and all malignant tumours.
Wide local excision
When a significant predetermined margin of surrounding
tissue is removed together with the primary mass, the
excision is termed 'wide local excision'. Again, preoper-
ative knowledge of the tumour type and grade, obtained
after appropriate biopsy, is essential in deciding on an
appropriate margin. An intermediate-grade mast cell
tumour of the skin will dictate a margin of 3 to 4 cm on
all boundaries, whereas a well differentiated dermal
squamous cell carcinoma will only require a margin of
I cm on all boundaries. Anatomical considerations may
dictate whether it is possible to resect the mass with the
appropriate margin, and consideration should be given to
the use of appropriate adjunctive therapy. Very often,
especially on the limbs, the appropriate depth of surgical
margin cannot be obtained without severely compromis-
ing function, and in these circumstances resection of a
carcinoma or mastocytoma should go as deep as a
grossly clean fascial plane. A collagen-rich fascial plane
(eg, a muscle sheath) that may act as a natural boundary
should be removed, as tumour cells will be infiltrating
the surface.
* INDICATIONS for wide local excision include benign
tumours with local infiltration (infiltrating lipoma) and
malignant tumours with limited infiltrative potential
(eg, well differentiated squamous cell carcinoma, low-
and intermediate-grade mast cell tumours).
* CONTRAINDICATIONS include malignant tumours with
considerable potential for local infiltration (eg, sarco-
mas).
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
enable effective surgical preparation of a
wide area around the proposed surgical site
and also to allow for any changes to the
surgical plan that may be required. Gentle
cleaning using effective skin preparations
(eg, a chlorhexidine/alcohol mixture) is suf-
ficent; inideed, vigorous scrubbing of skin
overlying tumours has been associated with
an increased rate of metastasis in laboratory
mice. Similarly, vigorous palpation of
tumours prior to surgery should be-avoided,
as damage to the surface of tumours,
especially intra-abdominal tumours, may
potentiate seeding of neoplastic cells or
rupture and haemorrhage.
Infection rates following oncological
surgery have been shown to be significantly
higher than for other surgical procedures,
both in the veterinary and human field. The
presence of cancer is not, in itself, a risk fac-
tor, but oncology patients often have one or
more of the factors that are associated with
an increased likelihood of postoperative
infection - namely, old age, poor nutritional
status, obesity, diabetes or other concurrent
disease, hypoxaemia, the presence of
remote infection, corticosteroid therapy,
immunocompromise, bowel obstruction,
thrombocytopenia and/or a poor blood
supply to the surgical field. Maximising the
chances of a successful surgery therefore
depends on careful planning for pharmaco-
logical prevention or treatment of infection.
Different classes of antibiotics kill organ-
isms in very different ways and the
appropriate dose schedules vary greatly. For
example, the flactams and clavulanic acid-
potentiated amoxycillin exhibit time-
dependent killing and should be dosed to
maintain concentrations of more than the
minimal inhibitory concentration for the
whole of the operative period, which may
mean repeat dosing (ie, every three hours
during surgery). The aminoglycoside and
quinolone (eg, enrofloxacin) antibiotics,
conversely, require a high peak concentra-
tion of the drug, which determines bacterial
killing, and then a period of low concentra-
tion to re-establish organism sensitivity; thus,
the goal in surgical prophylaxis is for the
organisms in the surgical field to encounter
just one large dose of the aminoglycoside or
quinolone during the operative period.
The timing of antibiotic prophylaxis is
crucial. If preoperative antibiotic therapy is
initiated too early or continued for too long
postoperatively, increased rates of infection
are observed. The best results are seen
when antibiotic therapy begins not more
than two hours before the surgical proce-
dure and continues for no longer than 24
hours post-surgery.

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

170 In Practice x A P R L 1 99 9
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lymph nodes appears only to be effective early on in the
course of disease. Local lymph node metastasis is com-
mon for malignant melanomas and most carcinomas,
intermediate for sarcomas, respiratory tumours, cuta-
neous carcinomas and mast cell tumours, and rare for
nervous system tumours, skeletal tumours, nasal tumours
and endocrine tumours. However, removing the lymph
nodes may interfere with local immune defence mecha-
nisms in the postoperative period. Another disadvantage
associated with their removal is the potential increase in
patient morbidity related to a more extensive surgical
procedure.
Decisions must be made on a case-by-case basis, but
current general recommendations are:
* Non-destructive biopsy of grossly normal local lymph
nodes.
i Lymph node removal when the node:
- is histologically proven to contain tumour cells;
- appears grossly abnormal at surgery;
- is intimately associated with the tissue being removed
0 00--0tschulq...t-0H j;:
In Practice 0 APRIL 1999
and surgical margins dictate its removal (eg, inguinal
lymph node removal during mastectomy).
Reconstruction of the resulting deficit
There is often a great temptation to compromise excision
margins through a lack of confidence in one's ability to
reconstruct the resulting deficit. However, compromising
the surgical margins may result in failure of a single surgi-
cal procedure that could have produced a cure and, poten-
tially, in the death of an animal that should have been cured.
It is the resection of tumours involving the skin and
associated structures that often results in substantial
deficits, and a variety of techniques are available to deal
with these deficits (see box below, and also Anderson
1997). The oncological surgeon should be familiar with
all of these techniques. It must be stressed that a suitable
closure technique should be planned prior to resection of
the tumour and that, should the resection have to be
more radical than originally planned, suitable altema-
tives for closure should have been considered.
171
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PALLIATIVE TREATMENT

As far as we know, animals have no comprehension of

lntraoperative radiotherapy
following cytoreductive
surgery on a bladder
transitional cell carcinoma.
Perspex is used as 'build-up'
to ensure that the correct
dose of radiation is
delivered to the bladder
wall
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
benefit must always be considered and patients selected
carefully.
TREATMENT OF ONCOLOGICAL
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

172 In Practice * APRIL 1999

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

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

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

Updated information and services can be found at:

http://inpractice.bmj.com/content/21/4/163

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