Cancer – no cure without surgery

New antibodies, more targeted radiation, gentler chemos: cancer medicine is constantly making progress. Surgery is also breaking new ground.

. and can thus heal more and more people. Your methods are gentler, but also more radical.

Cancer in the rectum, the stage already advanced. For Helga L., 67, the diagnosis was a shock. Investigations showed: five metastases in the liver, two in the lungs. "No more surgery," the doctors said – and gave her chemo to at least push the cancer back. But Helga L. wanted to fight, also for their children. At a cancer center, she sought a second opinion. Experts from different disciplines discussed the case – and saw an opportunity. In two steps, surgeons and radiologists first removed the liver metastases, and in a third procedure, the tumors in the rectum and lungs were operated on. Helga L. now has a realistic chance that the cancer is defeated in the long term.

Modern cancer surgery is more radical

Since then, she has been coming regularly to the Cancer Center of the University Hospital in Munich for follow-up checks. Since the beginning of the year, there Prof. Jens Werner the surgical clinics Grobhadern and Innenstadt. The experienced surgeon previously worked for many years at Heidelberg University Hospital in close cooperation with the cancer research center there and is an expert in the field of tumor surgery.

"Fewer and fewer tumors are now considered inoperable," says Werner. This also means that more and more patients have a chance of being cured. Even though cancer medicine has many new weapons at its disposal, one simple rule still applies: no surgery, no cure. At least for most solid tumors this is the case. This is what experts call growths that are localized – as opposed to, say, leukemias.

New techniques also make it possible to operate more gently in many cases. This is how cancer surgeons also use the laparoscope. The surgical instruments and a camera are inserted through small incisions. This transmits the images from inside enlarged on a screen. This is now standard practice for colorectal cancer. Surgical robots, controlled by a surgeon, are also used. The patient has less pain after surgery, wounds heal faster. "That can be important, especially in the case of cancer," says Werner. The procedure is often followed by other therapies such as radiation or chemo. For this purpose, the patient should be as fit as possible.

Fewer and fewer tumors are now considered inoperable

Minimally invasive techniques are also used for prophylactic, i.e. preventive, cancer surgery. Because sometimes healthy organs are also removed today – if a genetic test shows that it is almost certain that cancer will develop there. This is true, for example, for some forms of colon and stomach cancer. Modern cancer surgery is also more gentle because it realizes that diseased organs do not always have to be completely removed in order to cure the patient. For example, in the case of precancerous lesions or some cystic tumors of the pancreas, the organ can be preserved – and with it its function.

However, modern cancer surgery is not only gentler, but sometimes also more radical. Advanced tumors that no surgeon would have touched with a scalpel in the past can now be removed in some cases. Great progress has been made, for example, with tumors of the rectum and rectal tract, the liver and the pancreas.

Cancer of the pancreas in particular is often only discovered when it has already grown into blood vessels or affected other organs. If the tumor has affected surrounding organs, it is often possible to operate at specialized centers today. If necessary, surgeons remove several organs at once, for example, parts of the intestine, stomach or kidney in addition to the pancreas. Even tumors that have grown into vessels can usually be operated on. Including tumors that generally could not be removed in the past, for example, because they reach arteries. "Today, in such a case, the tumor area and the vessel are irradiated before surgery," Werner explains. Here, too, the surgeon is helped by the oncologist and radiologist.

Even metastases in the liver can often be removed

In addition, technical innovations are expanding the possibilities for therapy: If tumor foci are distributed in the abdominal cavity and peritoneum, the cancer was previously generally considered incurable. For some tumors, such as those of the intestine and stomach, a new method can sometimes even provide a long-term cure: HIPEC (hyperthermic intraperitoneal chemotherapy). Once the surgeon has removed the tumor, a chemotherapy solution heated to 40 degrees Celsius is introduced into the abdominal cavity for a few hours during the operation. This kills the tumor cells.

Even if the cancer is not present, as in the case of Helga L. If the cancer has already formed several metastases, healing is sometimes still possible. In the case of liver metastases, for example, the surgeon succeeds in working together with the radiologist. He performs an embolization of the portal vein, for example: The branch of the vein that supplies the diseased piece of liver is blocked, and the tissue is no longer supplied with blood. The diseased part shrinks, the healthy part grows. After a few weeks, it is large enough to completely take over the function after the diseased liver lobe is removed. "Even if there are some additional metastases in this part, you can often remove them," Werner explains. If they are located further inside, radiation or radiofrequency ablation can also be used. This involves inserting probes into the tumor and cooking it with an electric current.

The experience of the surgeon is also decisive for large operations. The risk is relatively high, especially in the case of radical surgery. Studies have shown that the surgical results and also the chances of recovery are significantly better in specialized centers.

The decisive factor for the patient is not only whether the tumor can be removed or not. Equally important: What does his life look like after surgery?? Here, too, it all depends on the surgical technique. About surgery on the anus. In the past, surgeons usually also removed the sphincter muscle. The patients then live with an artificial intestinal outlet. Today, the sphincter muscle can be preserved in over 90 percent of cases – and with it continence.

To protect nerves that are important for bladder and potency function, the surgeon must know exactly where to place the scalpel, laser or electric knife. For surgical instruments have also evolved, as has knowledge of anatomy. "You have to know the intricacies in the tissue structures," Werner says. Even experienced surgeons can still learn something new here.

By Sonja Gibis

The expert

Prof. Jens Werner has been the new director of the Department of General, Visceral, Transplant, Vascular and Thoracic Surgery at the Ludwig Maximilian University Hospital in Munich since the beginning of the year. Its specialties include cancer surgery and liver, kidney and pancreas transplants.

The best possible treatment

Cancer therapy today has many effective weapons. These are often particularly powerful in combination. How to use them correctly, however, knows only the expert. Even for the informed layperson, it is hard to see through whether he or she is really receiving the best possible therapy according to current knowledge. This is stated in the so-called medical guidelines. Studies, for example in breast cancer, have shown: If doctors adhere to these guidelines, patients have a significantly greater chance of being cured or at least living longer. But medical professionals do not always follow the guidelines.

But every patient can be sure that he or she is receiving therapy in accordance with the guidelines – by looking for a specific seal of approval: In certified centers, optimal therapy is guaranteed. To receive certification, clinics must meet strict requirements. So a minimum number of patients must be treated. Because also the experience has influence on the success. Extensive interdisciplinary work is standard here. In addition, social services and psycho-oncological care are always available in centers. Every two years is reassessed.

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