The Next Revolution in General Surgery
Ten years ago, laparoscopic surgery was introduced into general surgery practice from
an initial experience in gynecologic surgery. Led by the laparoscopic gallbladder
operation, this technology very quickly was used to perform appendectomy, inguinal hernia
repair, Nissen fundoplication, and cancer staging. Alone or in combination with
mini-laparotomy, the technique is now used for adrenalectomy, colon resection,
splenectomy, and nephrectomy. The experience has transformed general surgery practice in
both university centers and community hospitals.
This issue of Cancer Control focuses on the emerging field of radioguided
surgery, which has the potential of again changing the face of general surgery. Led by the
pioneering work of Donald Morton, MD, and colleagues at the John Wayne Cancer Center,
these investigators began with a melanoma model and showed first in animal work1 and
subsequently in humans 2 that the sentinel lymph node (SLN), defined as the
first node in the lymphatic basin that receives primary lymphatic flow, is the first site
of metastatic disease. Clinicians could obtain full nodal staging information from a lymph
node biopsy procedure, thereby obviating the need for a complete lymph node dissection
(CLND) and decreasing the morbidity for the patient and the costs for the health care
system. This initial experience in melanoma is reviewed by investigators at Moffitt and
M.D. Anderson Cancer Center. Lymphatic mapping and SLN biopsy have changed the standards
of surgical care for melanoma, particularly in light of the FDA approval of interferon
alfa-2b, the first effective adjuvant therapy for patients at high risk for recurrence of
melanoma. 3
The technology worked so well in melanoma that investigators were quick to try to apply
the technique to other tumor systems. What will probably drive this technology is its
applicability to breast cancer, since there is five times as many cases of breast cancer
diagnosed each year in the United States than melanoma, and breast cancer surgery is
performed widely. The Seattle group, headed by David Byrd, MD, and Ben Anderson, MD,
review the preliminary work with lymphatic mapping and breast cancer and provide a
perspective of its potential role in the surgical treatment of this disease. If 75% of
women with invasive breast cancer do not need to be exposed to the morbidity of a CLND,
this will be a major advance.
Investigators at Moffitt Cancer Center have successfully applied this technology to
other tumor systems. Patients with different skin tumors, such as the Merkel cell
carcinoma or the poorly differentiated squamous cell carcinomas (SCCs) — tumors that
have a 10% to 25% incidence of regional nodal metastases — can have nodal staging
with lymphatic mapping and SLN biopsy. Radioguided surgery of parathyroid adenomas with
the reagent sestamibi, and intraoperative use of the Neoprobe (Neoprobe Corp, Dublin, OH),
a hand-held gamma detector, results in successful localization in 82% of cases. These
harvests can be performed under local anesthesia with a two-inch incision in the neck, and
this exciting application is reviewed by James Norman, MD. It becomes very easy to
localize and perform a biopsy on bone tumors with the colloid used in a typical bone scan
and the Neoprobe for intraoperative localization (reviewed by Lary Robinson, MD). The
treatment for vulvar and vaginal melanomas or SCCs, where the standard of care had been
bilateral groin dissections with the resultant morbidity for women, can now be treated
with primary tumor excision, lymphatic mapping, and SLN biopsy. Finally, there is the
parallel concept of radioimmunoguided surgery, where a specific monoclonal antibody for
colon cancer determinants is injected intravenously, the deposits are localized
intraoperatively with the Neoprobe, and more thorough dissections are performed that
provide more accurate staging and perhaps a better survival. This approach is reviewed by
the initial proponents of this procedure, the Ohio State group headed by Edward W. Martin,
Jr, MD.
New advances and new technology do not come without problems. As the new techniques are
being introduced in the surgical community, questions arise as to who should be performing
the procedures and what should be required for the credentialing of clinicians. Hospital
credentialing is handle on a local hospital committee level, but national groups such as
the American College of Surgeons and the Society of Surgical Oncology are becoming
increasingly involved in formulating guidelines for surgeons and hospitals to follow.
Hopefully, the mistakes made for the credentialing of surgeons with laparoscopic
techniques will not be repeated, and the new techniques will be taught to surgeons by
surgeons instead of by sales people. Minimal criteria for credentialing should be
established and may include attendance at a formal course of instruction and proctoring of
the first cases before the surgeons can perform the procedure on their own.4 Training
sessions for radioguided surgery have been established at our center as well as at M.D.
Anderson Cancer Center and the University of Washington at Seattle.
More than 330,000 new cases of cancer are diagnosed annually in the United States to
which this new technology can be applied (Table). If both the number of procedures and the
demand for this minimally invasive approach are examined and compared to the laparoscopic
experience, the laparoscopic era was really led by the gallbladder operation, which
accounts for approximately 500,000 new cases per year. Certainly, this new technology has
the potential of changing the practice of general surgery and surgical oncology in the
United States. 
Douglas Reintgen, MD
Program Leader, Cutaneous Oncology
H. Lee Moffitt Cancer Center & Research Institute
Professor of Surgery
University of South Florida College of Medicine
References
- Wong JH, Cagle LA, Morton DL. Lymphatic drainage of skin to a sentinel lymph node in a
feline model. Ann Surg. 1991;214: 637-641.
- Morton DL, Wen DR, Wong JH, et al. Technical details of intraoperative lymphatic mapping
for early stage melanoma. Arch Surg. 1992;127:392-399.
- Kirkwood JM, Strawderman MH, Ernstoff MS, et al. Interferon alfa-2b adjuvant therapy of
high-risk resected cutaneous melanoma: the Eastern Cooperative Oncology Group Trial EST
1684. J Clin Oncol. 1996;14:7-17.
- Reintgen DS. The credentialing of American surgery. J Surg Oncol. 1997. In press.
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