1. Surgical Oncology

Question 1

A properly _____, performed & interpreted _____ is one of the most ______steps in the management of the cancer patient

Answer 1

timed; biopsy; crucial

Question 2

Pretreatment is an _______ biopsy and the post treatment is the ______ biopsy

Answer 2

Pre-treatment: Incisional Post-treatment: Excisional

Question 3

Performed in order to obtain additional information about the tumor prior to definitive tx

Answer 3

Pre-Treatment Incisional biopsy

Question 4

How to we procure an pre treatment incisional biopsy?

Answer 4

Needle core, wedge, & punch

Question 5

Pre treatment Incisional biopsy’s require a _____ _____ and we need to think about potential costs

Answer 5

second procedure

Question 6

The process of obtaining ________ information following surgical removal of the tumor is called….?

Answer 6

histopathological; Post Treatment “Excisional biopsy”

Question 7

Post treatment excision biopsy allows for a more ____ ____ of the disease process. Provides opportunity to evaluate completeness of excision (i.e. margins)

Answer 7

complete picture

Question 8

Is post treatment excision the best first option in general?

Answer 8

RARELY best 1st option for attaining a tissue diagnosis

Question 9

True or False

Do an excisional pre treatment FNA has provides information to allow you to continue adequate (surgical) planning for your patient…

Answer 9

False: FNA has provided insufficient information so incisional pre treatment to allow you to continue adequate (surgical) planning for your patient… be suspicious if false negative result and making life and death decisions on your FNA, your tumor grade will change your sx approach

Question 10

What are some general indications for when we should perform a pretreatment biopsy?

Answer 10

1. If your tx would likely be altered by the results 2. If owners willingness to treat would be altered by the results 3. If your surgery is in a difficult anatomic location so need to know ahead of time if sx is warranted 4. If treatment has a high morbidity 5. If an FNA has been non-diagnostic or equivocal

Question 11

YOU will almost NEVER be wrong if you choose to do a biopsy prior to treatment BUT….(state what is indicated)

Answer 11

– Your technique on how the biopsy is procured can influence the accuracy & effectiveness of the definitive intervention

Question 12

What are some of the Pro’s for pre-treatment incisional biopsy? (3)

Answer 12

• Better planning – Best chance for sx cure • Ability to establish informed consent – Counsel clients extensively prior to invasive therapy • Appropriate implementation of neoadjuvant & adjuvant treatments – “client decides not to do chemo PO after excisional biopsy when it is essential” • Could have prepared them better if tissue dx established prior to surgical excision

Question 13

What are some of the CON’s for pre-treatment incisional biopsy? (3)

Answer 13

• Two procedures - More invasive for patient - Progression while waiting to do definitive sx - More $$$ • Increased risk of local recurrence – But NOT if entire biopsy tract is excised during 2nd surgery

Question 14

What are some of the general considerations when taking a pre-treatment incisional biopsy?

Answer 14

• Avoid ulcerated/inflamed tissue • Delicate tissue handling – Avoid CAUTERY &CRUSHING • Plan closure – Do not compromise future sx • Sample size – Large & multiple samples • ***Orientation of incision***

Question 15

What are some of the different incisional biopsy techniques?

Answer 15

• Tru-cut • Punch biopsy • Wedge • Jamshedi/Michelle Trephine – Bone biopsy • Endoscopic/Laparoscopic • Specialized (organ specific)

Question 16

True cut biopsy can be used on ____ accessible mass. And one of the positives is that it _____ the structural integrity of the tissue. Can be performed under sedation or local anaesthesia. Do we obtain a single or multiple samples?

Answer 16

many; maintains; multiple

Question 17

For Punch Biopsy’s > _____(insert size parameter) to procure a diagnostic sample?

Answer 17

> 6mm

Question 18

True or False: Always try and use a punch biopsy for non visual hypo-dermal masses to make sure you get the sub-dermal tumor parts in your biopsy.

Answer 18

FALSE BEEETCH: Do not use for hypodermal masses unless you have visual exposure of the tissue you are sampling = Tissue shifts post biopsy & undetected HEMORRHAGE can occur

Question 19

What is the best option for punch biopsies?

Answer 19

Good for very small masses where you can punch out entire mass

Question 20

Wedge biopsy’s are preferred for ______ or ______ tumors

Answer 20

ulcerated or necrotic

Question 21

Wedge biopsy’s are preferred for ______ or ______ tumors that are _____ located masses such as (_____/____)

Answer 21

ulcerated or necrotic; deeply; (deep SQ/IM)

Question 22

What is the biggest problem with wedge biopsy’s?

Answer 22

Obtain sample at junction of normal/abnormal ideally but err on side of taking just tumor tissue if there is concern for increasing the field of contamination ****Remember - The entire biopsy tract must be removed at a later date ***Poorly planned wedges increase the chance of local recurrences & incomplete margins

Question 23

For wedge biopsies use ___ _____ to maintain tissue retraction for deeper lying tumors?

Answer 23

gelpi retractors

Question 24

“The first chance to due surgery to remove a tumor is the best chance to cure”

When is this principle compromised with excisional biopsy’s

Answer 24

This principle will be compromised if an excisional biopsy is performed improperly

Question 25

We do excisional biopsy’s When treatment would _____be altered by tumor type or grade (i.e a testicular mass)

Answer 25

NOT

Question 26

Consider the spleen and the considerations you need to think about when doing an excisional biopsy?

Answer 26

If the procedure to get to the mass is invasive (i.e. splenectomy) or carries

high risk (i.e. bleeding)

– Don’t biopsy a splenic mass - Just remove the entire organ so you won’t have to go back in if the biopsy confirms malignancy

Question 27

What is the reason for doing excisional biopsy’s in relation to wide margins?

Answer 27

• If the location is permissive of wide margins WITHOUT compromising the potential for future re-excision (if needed)

– i.e. Lateral thorax in a large breed dog with an undiagnosed 1cm x 1cm dermal mass/cyst

– Ideally, you would have done an FNA/cytology to confirm that the mass is benign before treating w/ an excisional biopsy

Question 28

Excisional Biopsy considerations:

____ mass

____location

____, ____, and history support a _____ diagnosis

Bad location like the ____ extremity perform a _____ biopsy

Answer 28

• Small mass
• Good location
• Cytology, exam & hx support a benign dx

Bad Location= incisional biopsy

Question 29

What is the main prevention considerations when performing an excisional biopsy? What do we not add to help eliminate fluid?

Answer 29

Prevention of tumor seeding - Avoid contamination of surrounding tissue:

– Minimize hemorrhage

– Eliminate all dead space (Seromas = BAD)

– Do not drain! (Disseminates cells throughout entire drainage tract in advent of incomplete excision)

Question 30

Majority of solid tumors are surrounded by a ______ (____ zone) which may contain microscopic tumor extensions or satellite populations of tumor cells.

The _____ of the excision is described in relation to this zone &

how close the cut was to this tissue

Answer 30

pseudocapsule (reactive); aggresiveness

Question 31

What is the name of the system for classification of surgical dosing? Spelling counts

Answer 31

ENNEKING system

Question 32

What are the aspects of the ENNEKING system

Answer 32

• Intralesional (curettage or debulking)
• Marginal (through the pseudocapsule or perilesional zone surrounding the tumor)
• Wide (in normal tissue outside the pseudocapsule)
• Radical (the entire compartment)

Question 33

The ______ aspect of the nneking system is one where you make an incison directly over the tumor, peel open skin and dig out tumor and reactive zone pseudocapsule.

Part B: True or False: best option to completely excise the tumor

Answer 33

Intracapsular

FALSE: Not a very good way to treat a tumor, never an indication to ever treat a malignant or benign tumor using a intracapusular resection you are contaminating that whole area, goal should be when you remove a tumor you never see the tumor or reactive zone you are working with normal skin ensuring you are getting those tendrils out.

Exception todo Intracapsular: Lipoma, benign tumor of fat, they can be peeled out and okay if breeched pseudocapsule in order to get around circumferance of the tumor