Exam 2- Surgical Oncology Flashcards
What are the 3 most crucial steps in the management of the cancer patient?
properly timed, performed and interpreted biopsy
Two types of biopsies:
Pre-treatment aka “incisional biopsy”
Post-treatment aka “excisional biopsy”
When is an incisional biopsy performed?
prior to the definitive treatment (sx) to obtain additional info about the tumor
Types of incisional biopsies?
needle core, wedge & punch
______ biopsy requires a 2nd procedure & potentially more costly than post-tx biopsy
Incisional/ pre-treatment
_______ is the process of obtaining histopathologic info following surgical removal of the tumor
Excisional biopsy/ post-treatment
Which biopsy method allows for a more complete picture of the disease process?
excisional biopsy/ post-treatment
T/F: excisional biopsy/post-treatment is usually the best option for attaining a tissue diagnosis
FALSE: RARELY the best option
Excisional biopsy/ post-treatment biopsy provides the _______ opportunity to evaluate of excision
completeness
ex. margins
What is the first thing we do when we have a tumor patient?
document size, location and movability of tumor
(body charts, callipers for dimentions)
When do we perform a pre-treatment biopsy?
- 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
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
your technique on how the biopsy is procured
Pros of incisional biopsy
- 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
Cons to incisional biopsy
- 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
When doing an incisional biopsy what type of tissue do we want to avoid?
ulcerated/inflammed tissue
We want to maintain delicate tissue handling so avoid ____ & _____
cautery & crushing
will distort the parimeter of tumor- not good for pathologist
What is important to remember when closing an incisional biopsy?
plan the closure- do not compromise future sx
****orientation of incision**** how will I close this? lines of tension!
Incisional biopsy incision orientation?
along lines of tension & in direction that wont increase surgical field for 2nd sx
Tru-cut biopsy
(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
Punch Biopsy
use for?
caution for what?
(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
Wedge biopsy
preferred for what type of samples?
(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
What is important to remember with wedge biopsy?
the entire biopsy tract must be removed at a later date
poorly planned wedges increase the chance of local recurrences & incomplete margins
During a wedge biopsy use _____ to maintain tissue retraction for deeper lying tumors
gelpi retractors
Use _____ biopsy when treatment would NOT be altered by tumor type or grade
excisional biopsy
If the procedure to get to the mass is invasive or carries a high risk we use a ____ biopsy
excisional
(dont biopsy a splenic mass, just remove the entire organ so you wont have to go back in if the biopsy confirms malignancy
If the location is permissive of wide margins W/O compromising the potential for future re-excision we do a ____ biopsy
excisional
If a tumor is in a bad location we recommend a _____ biopsy
incisional
If the mass is small, good location and cytology, exam & hx support benign dx then recommend a _____ biopsy
excisional
With excisional biopsy technique we need to prevent tumor seeding by?
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
The majority of solid tumors are surrounded by a _______ which may contain microscopic tumor extensions or satellite populations of tumor cells
pseudocapsule (reactive zone)
The aggressiveness of the excision is described in relation to the ____ & _____
reactive zone & how close the cut was to this tissue
______ system- classification of surgical dosing
enneking
4 components of Enneking system
- 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)
Intracapsular/intralesional
what would be the purpose?
cut made into tumor & pseudocapsule
***only real application unless purposely debulking is for lipoma excision***
Marginal
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***
Wide
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***
Radical
***removal of entire body compartment- limb or organ (spleen)***
Enneking classification- remember _____ TRUMPS everything else
most narrow margin
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 _____
marginal
Tumors located in what areas are commonly treated with marginal excision?
tumors on extremities, near important structures (eyes) or in perianal region
For wide excision: minimum of ______ lateral margins for MCT and a fascial plane deep
2cm
Common radial excision applications
amputations or hemipelvectomy
General rule for a mast cell tumor margin
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
Modified proportional margins technique
-complete margins in ___% of cases-
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
T/F we can eyeball our margin measurements
FALSE- rulers, sterile marking pens
Benign tumor surgical margins
1cm lateral & deep
Malignant soft tissue sarcoma margins
3cm (lateral) & fascial plane or 2 muscle planes deep
site specific variations can be made esp if grade has been determined & is low
Malignant mast cell tumor margins
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
T/F there is a lot of literature about surgical margins in the vet med database
FALSE- insufficient
Oral tumor surgical margins
acanthomatous ameloblastoma = 1cm (must get bone margin)
malignancies = 2cm laterally & bone margin deep
Inherently challenging margin sites
thyroid tumor and anal sac tumor excisions
-fortunately tumors well encapsulated in these regions so can get away w/ marginal excisions
T/F clients should have the option to test the tissue samples
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
For ALL tumors we need to INK the _____ surfaces and NOT the ____
INK cut surfaces
NOT the skin
-be sure to ink prior to bread loafing & prior to fixation in formalin
Ensure the ink drys _____ before placing specimen in formalin
`15-20mins
For specific orientation of specimen then label with?
different colors or use suture to tag ► dirty anywhere = DIRTY
provide clear description on the submission form denoting what the sutures/colors indicate
What is Davidson Dye System?
inexpensive and easy to work with
- use YELLOW or BLACK colors only
- red, green & blue dont stand out to pathologists
What type of info is needed for submission forms of tissue samples?
provide signalment, pertinent clinical info about tumor, anatomical site of sx & lesion description
Why is breed info important to a pathologist?
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
What is the formalin ratio for a sample?
Ideal tissue thickness?
1:10
for appropriate fixation = 0.5-1.0cm tissue thickness is ideally recommended
What is bread loafing?
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
What do we need to be cautious of when bread loafing?
avoid complete transection or too many cuts which can both result in loss of tissue orientation
T/F: if you have multiple lesions from a single animal, you can submit them together in a jar
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
Optimal method for a small volume biopsy submission?
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
A pathologist typically only evaluates _____ from an entire specimen that is submitted
1 to 4 sections
each section is usually only 5um thick
MAKE IT COUNT!
With what information is a prognosis & expected outcomes are established?
biologic aggressiveness of the tumor:
- type of tumor
- histologic grade
- histologic criteria, lymphatic and/or vascular invasion
- microscopic margins
What is a complete histologic margins? (not the number, describe)
where there are no tumor cells at the edge of the surgical excision = straight forward
_____ & _____ not present w/ INCOMPLETE margin terminology
uniformity & clarity
_____ excision has been used for canine MCTs excised w/ a histologic margin of <5mm
Narrow
Complete but close for tumor cells w/in ____ of the cut edge
1mm
______ excision sometimes defined as >2mm of normal tissue b/t the tumor & inked edges in all direction
complete
_____ excision = 2-5mm of normal tissue b/t tumor & cut edge
narrow
What are truly incomplete margins correlated with?
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
___ classification = very simplistic margin assesment scheme used in human surgical oncology for past 40 years
what is it good for?
R classification
validated in numerous tumor types as being strong prognostic indicator for local tumor control
R0 classification
no residual tumor
resection w/ HTFMs of >=1mm (clean but close/narrow)
R1 classification
microscopic residual tumor
resection w/ HTFM<1mm
lymphatic, venous, or perineural invasion
lymph node or microscopic distant metastasis
R2 classification
macroscopic residual tumor- not ideal
gross residual dz (intralesional resection)
just debulked it
If the microscopic dx doesnt make sense for the clinical picture, or if things just arent adding up.. what should we do?
get a biopsy review
What % of the time do pathologists agree on a dx evaluation?
ONLY 51% of the time
major disagreements 37% of the time (affecting treatment or prognosis)
When is it okay for us to biopsy through the lip?
NEVER- never cut the lip
Caudal palatal mass- How and where to biopsy?
Avoid midline & caudal!!
Lingual lesion- How and where to biopsy?
***Always stay rostral and lateral to not interfere w/ future surgery***
T/F: we can perform an excisional biopsy for a firm hypodermal mass in a cat
FALSE- you should NEVER
O will not allow amputation of leg so will the biopsy can change what you will do?
Only 1 option regardless of biopsy
