This is the decisive moment in the physical elimination of the tumor.

The surgical operation is also very important in order to confirm the preoperative staging performed by means of imaging examinations. These preoperative examinations are aimed at detecting the possible presence of metastases and assessing the local extension of the tumor. However, the real extension of the tumor can only be established during the surgical operation. Indeed, sometimes a situation that seems to be perfectly straightforward during the staging examinations turns out to be exactly the opposite, with the disconsolate surgeon saying, “There was nothing I could do; the tumor was much more invasive than the CT showed”. On the other hand, the opposite may happen; the preoperative tests indicate that it will be very difficult to remove the tumor, but the operation goes smoothly, the tumor is completely removed and the cancer-free margins of the cut are ample, which guarantees that the tumor has been radically (completely) removed.  

This underlines the importance of post-operative staging, which is first carried out in the operating theater and then certified in the anatomy department, where the surgical specimens are studied under the microscope. At the end of this process (surgical operation – analysis of the specimens removed) 3 situations can emerge, which are of enormous importance to the outcome of the patient. (FIGURE 6)

Fig 6. The three possible results of cancer surgery The cancer is the black irregular image. The margins of the surgical cut are represented by the square. R-0 means no cancer residue after the operation; R-1 means microscopic cancer residue after surgery, and R-2 means gross cancer residue after surgery.
  1. R-0  (“R-zero”). R stands for “residue”; zero means that no residual part of the tumor has been left in place by the surgical operation. With very few exceptions, this means that the patient has a good probability of being cured.
  2. R-1. Here, 1 stands for “microscopic residue”. This means that the surgeon reports having “removed everything”, but when the pathologist analyzes the specimens that have been removed, he/she finds that, in some places, the tumor extends to the margins of the specimen. Clearly, this situation is problematic; as the tumor tends to grow continuously, the few tumor cells left in place after the operation will continue to grow. Moreover, if it was difficult to remove the whole tumor during the first operation, because it was close to vital structures, it will be even more difficult to do so during a second operation, when the tumor has re-formed.
    However, we can take some consolation from the fact that an R-1 surgical result does not automatically mean failure, relapse and incurable disease. Admittedly, this is the most likely outcome, but there is still hope of a cure even in cases of an R-1 result.
    Indeed, when they remove the tumor, surgeons use a cautery (an instrument that cuts and burns at the same time), which coagulates the veins and arteries in order to avoid bleeding. This process kills a fairly thick layer of cells. In the case of an R-1 result, the number of tumor cells that may remain alive is very small (otherwise, the surgeon would have seen them and the staging would have been R-2); moreover, these few cells may have been completely destroyed by the cautery, and, if so, the patient may be cured even though the surgical result was R-1.
  3. R-2. If the tumor invades nearby vital structures and the surgeon is unable to remove the whole mass, the result of the operation will be R-2. In such cases, unfortunately, we are sure that a residual part of the tumor remains in place. The seriousness of this situation is obvious. 

Thus, the R stage is very important in determining whether the patient will be cured after the surgical operation. 

Unfortunately, however, even today many surgeons do not include this classification in the reports of their operations. In many cases, this is understandable, as information on the completeness of surgical removal of the tumor may not be available until the pathologist has examined the surgical specimens under the microscope. However, clarification should be sought in cases in which the pathologist’s examination does not clearly establish whether surgery has been radical (i.e., whether “all the tumor” has been removed or not).

Site map

To guarantee you a better experience of our website we use cookies. For more details or to manage consent click here.