Debulking surgery

Debulking surgery removes some, but not all, of a cancer tumor. Cancer debulking surgery is a surgical procedure whereby a surgically incurable malignant cancer or tumor is partially removed without curative intent in order to make subsequent therapy with drugs, radiation or other adjunctive measures more effective and, thereby, improve the length of survival. Debulking surgery is used when it’s not possible to remove all of a cancerous tumor — for example, because doing so may severely harm an organ — your doctor may remove as much as possible (debulking) in order to make chemotherapy or radiation more effective.

Debulking surgery has been advocated for carcinoma of the testis and ovarian cancer, a subtype of lymphoma, sarcoma, renal cell carcinoma, adrenal and other endocrine-related tumors, neoplasms of the central nervous system and other miscellaneous tumors ¹. Nonrandomized data indicate that surgical debulking is rarely indicated; however, complete resection of all gross disease following intensive chemotherapy is indicated for advanced carcinoma of the testis ². Complete or nearly complete resection of all gross disease prior to chemotherapy is indicated for advanced carcinoma of the ovary and possibly for Burkitt’s lymphoma. Prospective randomized studies of all three of these malignant conditions would be appropriate, and an evaluation of preoperative intensive chemotherapy for advanced carcinoma of the ovary and Burkitt’s lymphoma also may be warranted.

How is cancer surgery traditionally performed?

Traditionally, the primary purpose of cancer surgery is to cure your cancer by removing all of it from your body. The surgeon usually does this by cutting into your body and removing the cancer along with some surrounding healthy tissue to ensure that all of the cancer is removed.

Your surgeon may also remove some lymph nodes in the area to determine whether the cancer has spread. This helps your doctor assess the chance of your being cured, as well as the need for further treatment.

In the case of breast cancer surgery, your doctor may remove the cancer by removing the whole breast (mastectomy) or by removing only the portion of your breast that contains the cancer and some of the surrounding tissue (lumpectomy).

In the case of lung cancer surgery, your doctor may remove part of one lung (lobectomy) or the entire lung (pneumonectomy) in an attempt to ensure that all the cancer has been removed.

In both of these examples, the surgeon may also remove some lymph nodes in the area at the time of the operation to see if the cancer has spread.

What other techniques are used in cancer surgery?

Many other types of surgical methods for treating cancer and precancerous conditions exist, and investigators continue to research new methods. Some common types of cancer surgery include:

• Cryosurgery. During this type of surgery, your doctor uses very cold material, such as liquid nitrogen spray or a cold probe, to freeze and destroy cancer cells or cells that may become cancerous, such as irregular cells in your cervix that could become cervical cancer.
• Electrosurgery. By applying high-frequency electrical currents, your doctor can kill cancer cells, for example, in your mouth or on your skin.
• Laser surgery. Laser surgery, used to treat many types of cancer, uses beams of high-intensity light to shrink or vaporize cancer cells.
• Mohs surgery. Useful for removing cancer from certain sensitive areas of the skin, such as near the eye, and for assessing how deep a cancer goes, this method of surgery involves carefully removing cancer layer by layer with a scalpel. After removing a layer, your doctor evaluates it under a microscope, continuing in this manner until all the abnormal cells have been removed and the surrounding tissue shows no evidence of cancer.
• Laparoscopic surgery. A surgeon uses a laparoscope to see inside your body without making large incisions. Instead, several small incisions are made and a tiny camera and surgical tools are inserted into your body. The surgeon watches a monitor that projects what the camera sees inside your body. The smaller incisions mean faster recovery and a reduced risk of complications. Laparoscopic surgery is used in cancer diagnosis, staging, treatment and symptom relief.
• Robotic surgery. In robotic surgery, the surgeon sits away from the operating table and watches a screen that projects a 3-D image of the area being operated on. The surgeon uses hand controls that tell a robot how to maneuver surgical tools to perform the operation. Robotic surgery helps the surgeon operate in hard-to-reach areas.
• Natural orifice surgery. Natural orifice surgery is currently being studied as a way to operate on organs in the abdomen without cutting through the skin. Instead, surgeons pass surgical tools through a natural body opening, such as your mouth, rectum or vagina. As an example, a surgeon might pass surgical tools down your throat and into your stomach during natural orifice surgery. A small incision is made in the wall of the stomach and surgical tools pass into the abdominal cavity in order to take a sample of liver tissue or remove your gallbladder. Natural orifice surgery is experimental, and few operations have been performed this way. Doctors hope it can reduce the risk of infection, pain and other complications of surgery.

Cancer surgery continues to evolve. Researchers are investigating other surgical techniques with a goal of less invasive procedures.

What are the risks of cancer surgery?

What side effects you might experience after cancer surgery will depend on your specific surgery. In general, most cancer operations carry a risk of:

• Pain. Pain is a common side effect of most operations. Some cause more pain than others do. Your health care team will tell you how to keep your pain to a minimum and will provide medications to reduce or eliminate the pain.
• Infection. The site of your surgery can become infected. Your health care team will show you how to care for your wound after surgery. Follow this routine closely to avoid infection, which can lengthen your recovery time after surgery. In the rare instance where an infection does occur, your doctor will likely treat this with antibiotics.
• Loss of organ function. In order to remove your cancer, the surgeon may need to remove an entire organ. For example, a kidney may need to be removed (nephrectomy) if you have kidney cancer. For some such operations, the remaining organ can function sufficiently to compensate for the loss, but in other situations you may be left with impairments. For instance, removal of a lung (pneumonectomy) may cause difficulty breathing.
• Bleeding. All operations carry a risk of bleeding. Your surgeon will try to minimize this risk.
• Blood clots. While you’re recovering from surgery, you’re at an increased risk of developing a blood clot. Though the risk is small, this complication can be serious. Blood clots most commonly occur in the legs and may cause some swelling and pain. A blood clot that breaks off and travels to a lung (pulmonary embolism) is a dangerous and sometimes deadly condition. Your surgeon will take precautions to prevent blood clots from developing, such as getting you up and out of bed as soon as possible after your operation or prescribing a blood-thinning medication to reduce the risk of a clot.
• Altered bowel and bladder function. Immediately after your surgery, you may experience difficulty having a bowel movement or emptying your bladder. This typically resolves in a few days, depending on your specific operation.

Whatever cancer treatment your doctor recommends, you’re likely to feel some anxiety about your condition and the treatment process. Knowing what to expect can help.

Debulking surgery ovarian cancer

Debulking surgery is very important when ovarian cancer has already spread throughout the abdomen (belly) at the time of surgery. The aim of debulking surgery is to leave behind no visible cancer or no tumors larger than 1 cm (less than 1/2 an inch). This is called optimally debulked ³. Patients whose tumors have been optimally debulked, have a better outlook (prognosis) than those left with larger tumors after surgery called sub-optimally debulked ³.

In some cases, other organs might be affected by debulking surgery:

• Sometimes the surgeon will need to remove a piece of colon to debulk the cancer properly. In some cases, a piece of colon is removed and then the 2 ends that remain are sewn back together. In other cases, though, the ends can’t be sewn back together right away. Instead, the top end of the colon is attached to an opening (stoma) in the skin of the abdomen to allow body wastes to get out. This is known as a colostomy. Most often, this is only temporary, and the ends of the colon can be reattached later in another operation. For more information, see Colostomy Guide.
  Sometimes, a part of the small intestine may need to be removed. Just like with the colon, the small intestine can either be reconnected (which is most common) or an ileostomy might be made. This is usually temporary, but will need special care, so ask your doctor if this is a possibility before having surgery.
• Debulking surgery might also mean removing a piece of the bladder. If this happens, a catheter (to empty the bladder) will be placed during surgery. This will be left in place until the bladder recovers enough to be able to empty on its own. Then, the catheter can be removed.
• Debulking surgery might also require removing the spleen and/or the gallbladder, as well as part of the stomach, liver, and/or pancreas.

If both ovaries and/or the uterus are removed, you will not be able to become pregnant. It also means that you will go into menopause if you haven’t done so already. Most women will stay in the hospital for 3 to 7 days after the operation and can resume their usual activities within 4 to 6 weeks.

Debulking surgery ovarian cancer main points ⁴

• All patients with ovarian cancer should have a consultation with a gynecologic oncologist to help guide decision making.
• Patients with newly diagnosed, advanced ovarian cancer should have a single maximal surgical debulking effort to achieve minimal residual disease.
• Primary debulking surgery does make a clinically important difference and is the treatment of choice in specialized centers with a high success rate of achieving an optimal result.
• Neoadjuvant chemotherapy with interval debulking surgery is a good option for those patients not initially medically suitable due to extent of disease or medical comorbidities.
• Secondary debulking surgery may be beneficial for the relatively few patients who have an isolated relapse after a lengthy disease-free interval.

References

1. Khong, A., Cleaver, A.L., Fahmi Alatas, M. et al. The efficacy of tumor debulking surgery is improved by adjuvant immunotherapy using imiquimod and anti-CD40. BMC Cancer 14, 969 (2014). https://doi.org/10.1186/1471-2407-14-969
2. Surgical debulking of tumors. Surg Gynecol Obstet. 1982 Oct;155(4):577-85. https://www.ncbi.nlm.nih.gov/pubmed/6750827
3. Surgery for Ovarian Cancer. https://www.cancer.org/cancer/ovarian-cancer/treating/surgery.html
4. Schorge JO, McCann C, Del Carmen MG. Surgical debulking of ovarian cancer: what difference does it make?. Rev Obstet Gynecol. 2010;3(3):111–117. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046749