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Surgery > Exam 2- Surgical Oncology > Flashcards

Exam 2- Surgical Oncology Flashcards

1
Q

What are the 3 most crucial steps in the management of the cancer patient?

A

properly timed, performed and interpreted biopsy

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2
Q

Two types of biopsies:

A

Pre-treatment aka “incisional biopsy”

Post-treatment aka “excisional biopsy”

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3
Q

When is an incisional biopsy performed?

A

prior to the definitive treatment (sx) to obtain additional info about the tumor

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4
Q

Types of incisional biopsies?

A

needle core, wedge & punch

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5
Q

______ biopsy requires a 2nd procedure & potentially more costly than post-tx biopsy

A

Incisional/ pre-treatment

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6
Q

_______ is the process of obtaining histopathologic info following surgical removal of the tumor

A

Excisional biopsy/ post-treatment

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7
Q

Which biopsy method allows for a more complete picture of the disease process?

A

excisional biopsy/ post-treatment

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8
Q

T/F: excisional biopsy/post-treatment is usually the best option for attaining a tissue diagnosis

A

FALSE: RARELY the best option

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9
Q

Excisional biopsy/ post-treatment biopsy provides the _______ opportunity to evaluate of excision

A

completeness

ex. margins

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10
Q

What is the first thing we do when we have a tumor patient?

A

document size, location and movability of tumor

(body charts, callipers for dimentions)

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11
Q

When do we perform a pre-treatment biopsy?

A
  • when FNA has not been diagnostic to allow adequate surgical planning for your patient
    • when youre suspicious of false negative result
    • making life/death decisions based on your FNA results
    • tumor grade will change your surgical approach
  • if your tx would be altered by the results
    • type or extent
  • if owners willingness to treat would be altered by the results
  • if surgery is in a difficult anatomic location- you only get one shot at sx
  • if tx has high morbidity
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12
Q

You will almost never be wrong if you choose to do a biopsy prior to treatment BUT… ________________ can influence the accuracy & effectiveness of the definitive intervention

A

your technique on how the biopsy is procured

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13
Q

Pros of incisional biopsy

A
  • better planning- best chance for sx cure
  • ability to establish informed consent
    • can 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
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14
Q

Cons to incisional biopsy

A
  • requires 2 procedures
    • more invasive
    • progression while waiting to do definitive sx
    • more $$$
  • increased risk of local recurrence
    • but NOT if entire biopsy tract is excised during 2nd sx
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15
Q

When doing an incisional biopsy what type of tissue do we want to avoid?

A

ulcerated/inflammed tissue

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16
Q

We want to maintain delicate tissue handling so avoid ____ & _____

A

cautery & crushing

will distort the parimeter of tumor- not good for pathologist

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17
Q

What is important to remember when closing an incisional biopsy?

A

plan the closure- do not compromise future sx

****orientation of incision**** how will I close this? lines of tension!

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18
Q

Incisional biopsy incision orientation?

A

along lines of tension & in direction that wont increase surgical field for 2nd sx

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19
Q

Tru-cut biopsy

A

(incisional biopsy)

can be used on any accessible mass

maintains structural integrity of tissue

can be performed under sedation &/or local anesth

obtain multiple samples

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20
Q

Punch Biopsy

use for?

caution for what?

A

(incisional biopsy)

Use more than 6mm punch so pathologist can assess

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

good for very small masses ► punch out entire mass

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21
Q

Wedge biopsy

preferred for what type of samples?

A

(insicional biopsy)

preferred for ulcerated or necrotic tumors

preferred for deeply located mass (ex. deep SQ/intramuscular)

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

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22
Q

What is important to remember with wedge biopsy?

A

the entire biopsy tract must be removed at a later date

poorly planned wedges increase the chance of local recurrences & incomplete margins

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23
Q

During a wedge biopsy use _____ to maintain tissue retraction for deeper lying tumors

A

gelpi retractors

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24
Q

Use _____ biopsy when treatment would NOT be altered by tumor type or grade

A

excisional biopsy

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25
Q

If the procedure to get to the mass is invasive or carries a high risk we use a ____ biopsy

A

excisional

(dont biopsy a splenic mass, just remove the entire organ so you wont have to go back in if the biopsy confirms malignancy

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26
Q

If the location is permissive of wide margins W/O compromising the potential for future re-excision we do a ____ biopsy

A

excisional

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27
Q

If a tumor is in a bad location we recommend a _____ biopsy

A

incisional

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28
Q

If the mass is small, good location and cytology, exam & hx support benign dx then recommend a _____ biopsy

A

excisional

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29
Q

With excisional biopsy technique we need to prevent tumor seeding by?

A

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
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30
Q

The majority of solid tumors are surrounded by a _______ which may contain microscopic tumor extensions or satellite populations of tumor cells

A

pseudocapsule (reactive zone)

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31
Q

The aggressiveness of the excision is described in relation to the ____ & _____

A

reactive zone & how close the cut was to this tissue

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32
Q

______ system- classification of surgical dosing

A

enneking

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33
Q

4 components of Enneking system

A
  • intralesional (curettage or debulking)
  • marginal (through the pseudocapsule or periesional zone surrounding the tumor)
  • wide (in normal tissue outside the pseudocapsule)
  • radical (the entire compartment)
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34
Q

Intracapsular/intralesional

what would be the purpose?

A

cut made into tumor & pseudocapsule

***only real application unless purposely debulking is for lipoma excision***

35
Q

Marginal

A

cut made into pseudocapsule

***lateral margins <1cm for carcinomas, <2cm for mast cell tumors, <3cm for soft tissue and bone sarcomas & <5cm for feline injection- site sarcomas***

36
Q

Wide

A

cut is made in grossly normal tissue

***lateral margins >=1cm for carcinomas, >=2cm for mast cell tumors, >=3cm for soft tissue and bone sarcomas & >=5cm feline injection site sarcomas***

37
Q

Radical

A

***removal of entire body compartment- limb or organ (spleen)***

38
Q

Enneking classification- remember _____ TRUMPS everything else

A

most narrow margin

39
Q

You could do a very radical surgery 99% of the way through & then engage the pseudocapsule in one small area and the whole procedure needs to be classified as _____

A

marginal

40
Q

Tumors located in what areas are commonly treated with marginal excision?

A

tumors on extremities, near important structures (eyes) or in perianal region

41
Q

For wide excision: minimum of ______ lateral margins for MCT and a fascial plane deep

A

2cm

42
Q

Common radial excision applications

A

amputations or hemipelvectomy

43
Q

General rule for a mast cell tumor margin

A

3cm lateral & 1 fascial plane deep

  • necessary margins found to be grade dependent
  • Gr I- 100% clean @ 1,2 &3cm
  • GR II- 68% clean @ 1cm
    • 90% clean @ 2cm margins
    • 100% clean @3cm margins
44
Q

Modified proportional margins technique

-complete margins in ___% of cases-

A

MCT excision

widest diameter of tumor used as the lateral margin for excision

**complete margins obtained in 82% of cases**

if more than 4cm- use a fixed 4cm margin

45
Q

T/F we can eyeball our margin measurements

A

FALSE- rulers, sterile marking pens

46
Q

Benign tumor surgical margins

A

1cm lateral & deep

47
Q

Malignant soft tissue sarcoma margins

A

3cm (lateral) & fascial plane or 2 muscle planes deep

site specific variations can be made esp if grade has been determined & is low

48
Q

Malignant mast cell tumor margins

A

knowing that 10% of GR II (most common- 85%) will be incompletely excised w/ 2cm margins = always go for 3 cm if your location is permissive. otherwise, reasonable to go 2cm margins

Vs modified proportional margin technique

49
Q

T/F there is a lot of literature about surgical margins in the vet med database

A

FALSE- insufficient

50
Q

Oral tumor surgical margins

A

acanthomatous ameloblastoma = 1cm (must get bone margin)

malignancies = 2cm laterally & bone margin deep

51
Q

Inherently challenging margin sites

A

thyroid tumor and anal sac tumor excisions

-fortunately tumors well encapsulated in these regions so can get away w/ marginal excisions

52
Q

T/F clients should have the option to test the tissue samples

A

FALSE: if it was worth removing than it is worth figuring out what you removed… dont give them an option

in accordance w/ ethical practice standards, it is our policy that all excised masses must be processed for microscopic interpretation

53
Q

For ALL tumors we need to INK the _____ surfaces and NOT the ____

A

INK cut surfaces

NOT the skin

-be sure to ink prior to bread loafing & prior to fixation in formalin

54
Q

Ensure the ink drys _____ before placing specimen in formalin

A

`15-20mins

55
Q

For specific orientation of specimen then label with?

A

different colors or use suture to tag ► dirty anywhere = DIRTY

provide clear description on the submission form denoting what the sutures/colors indicate

56
Q

What is Davidson Dye System?

A

inexpensive and easy to work with

  • use YELLOW or BLACK colors only
  • red, green & blue dont stand out to pathologists
57
Q

What type of info is needed for submission forms of tissue samples?

A

provide signalment, pertinent clinical info about tumor, anatomical site of sx & lesion description

58
Q

Why is breed info important to a pathologist?

A

many neoplasms are breed related & the pathologist may know them even if we dont

list ranked DDX based on clinical impression of the tumor/disease process ► be bold & proud

59
Q

What is the formalin ratio for a sample?

Ideal tissue thickness?

A

1:10

for appropriate fixation = 0.5-1.0cm tissue thickness is ideally recommended

60
Q

What is bread loafing?

A

INCOMPLETE parallel cuts at a minimum of 2cm apart

can be performed on large specimens

specimens can be held to fix (at least 24hrs) before shipping

61
Q

What do we need to be cautious of when bread loafing?

A

avoid complete transection or too many cuts which can both result in loss of tissue orientation

62
Q

T/F: if you have multiple lesions from a single animal, you can submit them together in a jar

A

FALSE- submit each specimen individually in its own respective & appropriately labeled jar

multiple specimens submitted in single jar (less ideal) - need to be identifies from one another respective to anatomical sites

63
Q

Optimal method for a small volume biopsy submission?

A

place sample in a screen cassette

after which cassette should be placed in an appropriately labeled formalin jar

you can put multiple cassettes into 1 jar. label cassettes

64
Q

A pathologist typically only evaluates _____ from an entire specimen that is submitted

A

1 to 4 sections

each section is usually only 5um thick

MAKE IT COUNT!

65
Q

With what information is a prognosis & expected outcomes are established?

A

biologic aggressiveness of the tumor:

  • type of tumor
  • histologic grade
  • histologic criteria, lymphatic and/or vascular invasion
  • microscopic margins
66
Q

What is a complete histologic margins? (not the number, describe)

A

where there are no tumor cells at the edge of the surgical excision = straight forward

67
Q

_____ & _____ not present w/ INCOMPLETE margin terminology

A

uniformity & clarity

68
Q

_____ excision has been used for canine MCTs excised w/ a histologic margin of <5mm

A

Narrow

69
Q

Complete but close for tumor cells w/in ____ of the cut edge

A

1mm

70
Q

______ excision sometimes defined as >2mm of normal tissue b/t the tumor & inked edges in all direction

A

complete

71
Q

_____ excision = 2-5mm of normal tissue b/t tumor & cut edge

A

narrow

72
Q

What are truly incomplete margins correlated with?

A

higher rates of recurrence for most tumors but is OFTEN unclear if a narrow margin is to be considered incomplete

recommended more tx w/ a narrow margin report BUT this recommendation is unfounded scientifically

73
Q

___ classification = very simplistic margin assesment scheme used in human surgical oncology for past 40 years

what is it good for?

A

R classification

validated in numerous tumor types as being strong prognostic indicator for local tumor control

74
Q

R0 classification

A

no residual tumor

resection w/ HTFMs of >=1mm (clean but close/narrow)

75
Q

R1 classification

A

microscopic residual tumor

resection w/ HTFM<1mm

lymphatic, venous, or perineural invasion

lymph node or microscopic distant metastasis

76
Q

R2 classification

A

macroscopic residual tumor- not ideal

gross residual dz (intralesional resection)

just debulked it

77
Q

If the microscopic dx doesnt make sense for the clinical picture, or if things just arent adding up.. what should we do?

A

get a biopsy review

78
Q

What % of the time do pathologists agree on a dx evaluation?

A

ONLY 51% of the time

major disagreements 37% of the time (affecting treatment or prognosis)

79
Q

When is it okay for us to biopsy through the lip?

A

NEVER- never cut the lip

80
Q

Caudal palatal mass- How and where to biopsy?

A

Avoid midline & caudal!!

81
Q

Lingual lesion- How and where to biopsy?

A

***Always stay rostral and lateral to not interfere w/ future surgery***

82
Q

T/F: we can perform an excisional biopsy for a firm hypodermal mass in a cat

A

FALSE- you should NEVER

83
Q

O will not allow amputation of leg so will the biopsy can change what you will do?

A

Only 1 option regardless of biopsy

Surgery (15 decks)

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