What size carcinoma tumors can we operate on?

Surgical Management of Carcinoma Based on Tumor Size

For most carcinomas, surgical resection is recommended for tumors up to 3-4 cm in size, with specific size thresholds varying by cancer type and location. 1

Breast Carcinoma

• For breast cancer, tumors up to 3-4 cm are generally suitable for breast-conserving surgery, while larger tumors may require mastectomy 1
• Very early breast tumors (<2 cm) have excellent 5-year survival rates of 80-90% with surgical resection 1
• Contraindications to breast-conserving surgery include multicentric tumors, large tumors (>3-4 cm) in small breasts, retroareolar location, and tumor-involved margins after resection 1
• For ductal carcinoma in situ (DCIS), complete surgical resection is recommended, with adjuvant radiation for breast-conserving approaches 1

Hepatocellular Carcinoma (HCC)

• For very early HCC (single tumor <2 cm), both surgical resection and radiofrequency ablation (RFA) offer similar survival outcomes 1
• For single HCC regardless of size, liver resection can be offered with definitive survival advantage over other treatments, especially for tumors >5 cm 1
• Tumor size and location influence surgical approach:
  • For single HCCs ≤2 cm deeply/centrally located, RFA offers competitive results compared to liver resection 1
  • For superficial or peripheral tumors, laparoscopic-robotic liver resection provides optimal outcomes 1
• Surgical outcomes decrease as tumor size increases, with tumors >5 cm having worse prognosis despite being technically resectable 1

Lung Carcinoma

• Surgery should be offered to all patients with stage I and II non-small-cell lung cancer (NSCLC) 1
• For non-centrally located resectable tumors without nodal metastasis on CT and PET, surgical resection is recommended 1
• Lobectomy is considered the standard surgical treatment for tumors ≥2 cm with solid appearance on CT 1
• For smaller tumors:
  • Anatomical segmentectomy is acceptable for pure ground-glass opacities or adenocarcinomas in situ 1
  • Video-assisted thoracoscopic surgery (VATS) should be the approach of choice for stage I tumors 1

Neuroendocrine Tumors

• For small (<2 cm) peripheral pancreatic neuroendocrine tumors, enucleation or local excision with peripancreatic lymph dissection may be considered 1
• For larger (>2 cm) or malignant-appearing tumors, more extensive resection is recommended with negative margins and regional lymph node removal 1
• For tumors in the pancreatic head, pancreatoduodenectomy with resection of peripancreatic lymph nodes is recommended 1
• For distal tumors, distal pancreatectomy with splenectomy is typically performed 1

General Considerations for Surgical Decision-Making

• Surgical resection is associated with substantially higher cancer-specific survival rates across all stages compared to non-surgical approaches 2
• Patient factors influencing surgical decisions include:
  • Age (though age alone should not be a contraindication with adequate performance status) 1
  • Comorbidities and performance status 1
  • Cardiopulmonary fitness (especially for lung resections) 1
• For multifocal cancers, complete resection should be attempted whenever possible 1

Caveats and Pitfalls

• Tumor size alone should not be the only determinant for surgical decision-making; other factors such as tumor location, patient performance status, and organ function must be considered 1
• For hepatocellular carcinoma, liver function assessment is critical before considering resection to avoid post-operative liver failure 1
• For lung cancer, formal lung function testing should be undertaken to estimate postoperative lung function before surgical resection 1
• The goal of cancer surgery should be complete resection with negative margins to maximize survival benefit 2, 3
• Patient involvement in surgical decision-making is important and may influence treatment choice, with more involved patients sometimes opting for more extensive surgery 4

Remember that these guidelines represent general recommendations, and the multidisciplinary tumor board should discuss each case individually, considering all relevant clinical factors to determine the optimal surgical approach 1.