Tumor removal

Anatomy or system affected: All (primarily brain, breasts, gastrointestinal system, intestines, lungs, respiratory system)

Definition: The removal—through surgery, chemotherapy, or radiotherapy—of any neoplasm.

Indications and Procedures

The uncontrolled, progressive growth of cells, termed a neoplasm, usually results in a mass or tumor. The tumor may be malignant (cancerous) or benign. Generally, benign tumors remain localized, are often encapsulated, and contain cells that remain well differentiated. Since the cells of a benign tumor do not metastasize, the tumor is usually less of a threat to life. The site of the tumor, however, can be as critical as its malignant or nonmalignant state: tumors within inoperable portions of the brain may pose a threat regardless of whether they are malignant.

Most tumors are initially observed as localized masses of cells, or lumps. Any symptoms that occur result from tumor growth in this particular tissue. While any tissue or cell is at risk for the development of a tumor, most such forms of uncontrolled growth are found in the female breasts, the colon, and the lungs, the latter a result of the increased use of cigarettes in the twentieth century.

When a tumor is observed, several options exist for its elimination. Surgery remains the method of choice when applicable. This method poses two advantages: under ideal circumstances, surgery can result in complete removal of the tumor and total cure; in addition, the removal of the tissue allows for proper diagnosis, and subsequent prognosis, of the form of tumor. Surgery may also play a palliative role, allowing for elimination of some of the tumor mass, temporary relief of symptoms, and a greater chance for alternative forms of therapy to effect a cure.

While alternative methods of noninvasive diagnosis were developed during the latter half of the twentieth century, most notably computed tomography (CT) scanning and magnetic resonance imaging (MRI), surgery remains the best method for both tumor diagnosis and cure. The procedure for diagnosis of most tumors is relatively straightforward. When the patient is examined, a complete analysis of symptoms is carried out. The tumor, though not necessarily its prognosis, may be directly observable, such as a lump in the breast. Sometimes, symptoms may be secondary, such as blood in the feces resulting from a tumor in the colon or a cough associated with lung cancer. Biopsy of the material, often in conjunction with surgery, may be necessary to determine whether the tumor is malignant; many tumors are not. If the tumor is determined to be malignant, the material obtained in the biopsy may also be useful in determining the staging of the tumor, a classification system used to identify the extent of the tumor, its degree of spread, and the likely prognosis. Though several methods of staging are used, the most popular is the TNM system. T refers to the size of the tumor (T0 to T4, depending on its size), N refers to the extent of lymph node involvement (N0 to N2), and M indicates whether metastasis has occurred (M0 or M1).

If the tumor is localized, surgical removal remains the best chance for a cure. In general, the patient is anesthetized, and the region of the tumor is surgically removed. For a tiny breast tumor, this may involve a lumpectomy (removal of the lump only). For larger tumors, extensive amounts of tissue may have to be excised. Surgery usually involves the use of a knife, though alternative forms, such as laser surgery or electrosurgery, may be used under specific circumstances. The surgeon will attempt to remove the area of cancer or, when warranted, the entire organ and a margin of adjacent normal-looking tissue, if a few cells have spread beyond the visible tumor. Localized lymphglands may also be removed, both to estimate the chance of metastasis and to improve the chance of removing all the tumor since the local lymph nodes are generally the sites to which cancer cells initially spread.

When the tumor is too large, or if metastasis has occurred, additional forms of treatment to effect tumor removal may be needed. Radiation therapy, the use of beams of high-energy X-rays or radioactivity, may be used to reduce the size of a tumor or to eliminate any cancer cells that remain in the vicinity of an excised tumor. Chemotherapy, the use of metabolic poisons, is often employed when the tumor has spread beyond its initial site.

Tumor removal may also be palliative, a procedure employed for the reduction of symptoms or for the restoration of normal organ function. For example, the removal of a tumor on the colon may reduce pain and restore function temporarily, even if the tumor has spread and the prognosis is poor. Common benign tumors may also cause discomfort, even if not life-threatening. Nearly one-quarter of women over the age of thirty develop fibroid tumors on the wall of the uterus, a condition which is more of a nuisance than dangerous; surgical removal of such tumors may be necessary to eliminate pain or bleeding.

The decision regarding the methodology of tumor removal often depends on the site and extent of the tumor. The biopsy of the material may be immediately followed by surgical removal of the tumor while the patient remains under anesthesia. This is often the method of choice if the tumor is small or confined to a single organ. After surgery, any additional options can be discussed with the patient. If various options exist for tumor removal, the results of the biopsy may first be discussed with the patient, and a decision on specific forms of treatment may follow.

The most convenient procedure for biopsy during surgery is needle aspiration, the insertion of a small needle into the tumor for the removal of a small number of cells. If more tissue is needed, a larger needle may be used. If the tumor is small enough, the entire tumor may be removed at this stage.

When the tumor has been removed, the entire tissue is given to a pathologist. Analysis of this gross specimen allows for a firmer diagnosis of the form of tumor, its staging, and a possible prognosis.

Uses and Complications

Two strategies are associated with tumor removal: First is the attempt to effect a cure. Ideally, complete elimination of a malignant tumor will result in a cure for the disease. The assumption in this case is that metastasis has not occurred. If the tumor is benign, removal should alleviate any symptoms associated with its growth. As indicated above, fibroid tumors of the uterus, while common in middle-aged women, rarely pose a threat to life; it is their very presence that results in discomfort or other symptoms. Likewise, parotid tumors, growths in the salivary gland, may result in unsightly lumps in the region of the jaw, as well as pain or discomfort; on some occasions, there may be facial paralysis. Removal of the tumor, generally through surgery but with radiation or chemotherapy if the condition warrants, may be indicated.

Colon cancer is one of the more common forms of cancer among adults. Symptoms include rectal bleeding, diarrhea, loss of weight, and loss of appetite. If a patient complains of such symptoms, the physician will likely recommend a rectal examination, including the removal of tissue for biopsy, generally as part of a colonoscopy (the visual examination of the colon with a flexible fiber-optic tube).

Treatment for colon cancer depends on the results of the biopsy and the general health of the patient. Surgical removal, however, is the most common treatment. If the tumor is small and confined, as in the form of a polyp, the removal of the polyp (polypectomy) is usually sufficient to effect a cure. If the tumor is relatively large, both the tumor and surrounding tissue must be removed (wedge resection). The extent of tissue removal depends on the size and stage of the tumor. Complete removal often includes supplementary treatments such as chemotherapy or radiation therapy. Since metastasis often occurs by the time symptoms appear, the prognosis for colon cancer is often poor.

Surgical procedures for smaller, more accessible tumors in other parts of the body are more straightforward. In the case of a parotid tumor, diagnosis often includes a CT scan or MRI, along with a biopsy. If the tumor is benign, removal of the lump is relatively simple. In rare instances in which the tumor is malignant, radiation therapy may be included as part of the treatment.

Breast cancer is one of the more common forms of cancer in women. In addition to its life-threatening potential, the disease can result in disfigurement because of treatment.

Breast cancer often is first observed as a lump in the breast. If the biopsy shows it to be malignant, several courses of action may be considered, usually associated with surgical removal of the tumor along with healthy surrounding tissue. If the tumor is very small, removal of the lump may be sufficient; if the tumor has spread, complete removal of the breast is often the choice (mastectomy). Radical mastectomy, which also involves the removal of surrounding muscle, may be necessary if the cancer has spread into that tissue. Nearby lymph nodes from the armpit (axillary nodes) are often included to evaluate whether the cancer has metastasized.

Perspective and Prospects

The first attempts at the surgical removal of tumors date to as early as 1600 BCE in Egypt. These procedures were obviously crude and limited. Modern surgical treatment for tumor removal is credited to the American surgeon Ephraim MacDowell, who, in 1809, removed a twenty-two-pound tumor from a patient. (The patient survived and lived another three decades.) Two complications limited such forms of surgery, even for localized, readily accessible tumors: pain and infection. Though poppy extracts and drinking alcohol were used to deaden pain in earlier centuries, it was not until the routine use of ether in the mid-nineteenth century that pain could be eliminated from surgery. In 1846, William T. G. Morton demonstrated the use of ether as a general anesthetic, first in the extraction of a tooth and later in a public demonstration in which a vascular tumor of the jaw was removed from a young patient. The pain-free operation lasted nearly thirty minutes and ushered in the era of general surgery.

Though pain during surgery could now be eliminated, there was still the problem of infection. Tumor removal in the mid-nineteenth century was confined to those of the breast or superficial areas of the body. It remained for Joseph Lister in the 1860s and 1870s to develop the antiseptic procedures necessary to reduce the chances for infection and subsequent mortality associated with surgery as a means of tumor removal.

Surgical procedures continued to improve in the twentieth century. Following the discovery of radioactivity by Wilhelm Conrad Röntgen, the use of X-rays was added to the repertoire for the elimination of tumors. By damaging the genetic material of cells, radiation was demonstrated to be capable of reducing the size of tumors or of eliminating localized tumors altogether. The discovery in the mid-twentieth century of chemicals that interfere with the growth or metabolism of cancer cells resulted in the development of chemotherapy as a method of treatment.

Technological advances have resulted in better methods both for the diagnosis of tumors and in their elimination. Both CT scanning and MRI have the advantage of being noninvasive, though surgical biopsy remains the method of choice for diagnosis and staging of a tumor. Along with the development of these techniques have come more aggressive forms of treatment. Until the 1970s, tumor removal generally involved surgery, chemotherapy, or radiation therapy, but not often in combination. It became apparent that the elimination of the tumor was more effective when these procedures were used together: radiation therapy could be used first to shrink the tumor, allowing for more effective surgical removal. As knowledge of the immunology of cancer (and the immune system in general) developed, physicians began to apply the immune system itself as a form of therapy. Interleukins and other chemicals secreted by the body’s immune cells were seen to boost the immune response, aiding in the killing of tumor cells.

Many of the future goals in this medical field center on the prevention of tumor formation, as well as their elimination. It is known that certain carcinogens, such as cigarette ingredients, are involved in the induction of tumors. Reduction in the number of persons smoking would have a significant impact on the prevalence of smoking-related tumors of the mouth and respiratory system. In addition, many tumors have been found to have a genetic basis; specific forms of cancer are associated with oncogenes in the cell. Through periodic screening, it is possible to observe whether such genes have undergone mutation and to remove any tumors that occur while they are still small and before they have undergone metastasis.

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