Sebastian G. de la Fuente, Director Hepato-Pancreato-Biliary fellowship, Florida Hospital
Never has the surgical oncologist had so many tools at his/her disposal for the care of the patient in need of oncologic surgical interventions. Drastic improvements over the last decades in the preoperative diagnostic process allow for better planned surgeries that result in enhanced postoperative long-term outcomes. Advances in anesthesia care facilitate the performance of complex oncologic interventions that not long ago were unimaginable. The current use of targeted systemic therapies for the pre-operative treatment of some tumors, which are associated with decreased toxicities and side effects, have significantly improved the overall survival for the oncologic patient. Precise radiation therapy approaches that limit the doses of radiation exposure to healthy tissues, which result in decreased postoperative morbidity in those patients who require surgical interventions following treatment.
"Robotic technologies have proven safe and permit for outstanding visualization of the surgical field"
Today, surgeons who care for oncologic patients use a wide spectrum of diagnostic tools to determine resectability of the cancer prior to surgery, decreasing the uncertainty and minimizing the need for “exploratory surgery”. A clear understanding of the surgical oncologic anatomy and relationship of the tumor to unaffected tissues can be establish preoperatively in a high percentage of patients with accuracy and precision. Rationalization of highly sensitive imaging studies have decreased the number of patients that are subject to unnecessary interventions and therefore, favoring other therapies.
The old paradigm that “big tumors require big incisions” is being constantly challenged by the utilization of minimally invasive approaches that facilitate access to cavities through smaller incisions expediting recovery while maintaining sound oncologic principles. Robotic technologies have proven safe and permit for outstanding visualization of the surgical field. Flexible robotic platforms, articulating instruments and robots that provide tactile feedback are already available for surgeons to use. Currently, it is estimated that less than 4 percent of all surgeries are done robotically in the US but that number is poised to grow exponentially in the next decade, as costs decrease and more platforms become available.
Another area that will likely see significant growth in the next decade is the use of ablative techniques for tumors that are technically not possible to be removed. Cryoablation, radiofrequency and microwave ablation and irreversible electrophoresis are used in the treatment of tumors affecting solid organs. These techniques are often done in the outpatient setting and therefore with minimal interruption of other therapeutic strategies.
Lately, devices that facilitate localization of malignancies intraoperatively have been introduced although not yet fully proven to be better than a trained pathologist examining a specimen under the microscope. GPS navigation systems are being developed to simplify localizations of tumors within the parenchyma of solid organs such as the brain or liver, providing better local control of the cancer.
In a recent teaching conference at our institution, I was approached by a medical student asking my opinion regarding the future of surgical oncology. Will the need for surgical intervention in the oncologic patient ever disappear with the introduction of more effective-less-toxic chemotherapeutic agents? Will patients one day be treated with effective targeted or immune-regulated therapies in the outpatient setting that will result in complete oncologic cure? While this is unlikely, certainly the way we practice surgical oncology will change markedly in the near future, as our understanding of the pathophysiology of cancer continues to evolve.