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ONCOLOGY & CC > Oncology Biopsy and Surgery > Flashcards

Oncology Biopsy and Surgery Flashcards

1
Q

What is the leading natural cause of death in adult dogs

A

Cancer - 50% of dogs

Cats (2nd or 3rd) - 30-35% of cats

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2
Q

Why is there so much more cancer in pets?

A

Better pet health care = longer life
-vaccinations, preventative medicine
-nutrition
-leash laws, more pets indoors and/or supervised
-cancer is a disease of old age and we’re seeing more and more older pets

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3
Q

What is the association of environmental factors causing cancer in pets

A

weak associations between certain types of cancer and environmental influences
-K9 LSA and certain herbicides or urban environments
-K9 mesothelioma and asbestos
-Feline GI LSA and environmental tobacco smoke (ingest material on fur)

but in most cases, no strong associations

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4
Q

What cancer might make you want to investigate for potential environmental causes

A

K9 mesothelioma

-asbestos shown to increase cause

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5
Q

For the most part, food additives, lawn chemicals, pesticides, cosmic rays do not

A

meaningfully increase cancer risk

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6
Q

Why do we treat animals with cancer

A

Because we can!
-Cancer is a chronic disease (like diabetes, endocrine diseases, heart disease)
-Cancer is a disease we can sometimes cure
-Even in cases where cure is unlikely, there are many cancers where we can extend an excellent quality of life with treatment

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7
Q

T/F: needle aspiration cytology/ biopsy hastens the spread of the tumor

A

False-
-mast cell tumors could get inflammed but doesnt increase likelihood that it might spread
-not true in sarcoids
-splenic mass disruption potential (excess ion)

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8
Q

T/F: removing the primary tumor makes metastasis more likely

A

False- there is so much that goes into metastasis

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9
Q

Why do an FNA / Incisional Biopsy

A

helps plan your surgical approach (mast cell vs lipoma)
if already metastasis

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10
Q

What should you tell the owner if a tumor excision is used for diagnosis

A

forewarn owner that additional treatment/diagnostics may be necessary

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11
Q

What should you do if clients wont pay for histopathology after removing a tumor

A

incorporate into surgery fee- does not need to appear as line item on invoice/estimate

-if its worth removing, its worth submitting

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12
Q

What is the concern with submitting half of the tumor or “representative section”

A

cuts the info learned from the pathology report in half (margins not evaluable)
talk to your pathologist if you need to submit a very big sample

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13
Q

T/F: recurrent tumors are often much worse than first time tumors

A

True
-dont wait to submit for histo if it recurs
-dont wait to get aggressive or think about additional therapy if it recurs

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14
Q

Recurrent tumors are often much more likely to

A

-Grow back worse than first time tumors
-Grows back twice as fast
-Open and bleeding and painful
-Some tumors more likely to spread

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15
Q

Why do tumors get more aggressive and grow faster after incomplete resection

A

-You are selecting for cells that grow on the periphery around the mass and they are more successful at expanding (potentially higher metastatic rate)

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16
Q

What are 3 components of a pathology report

A

-Histotype
-Histologic grade (when applicable)
-Margins (must be interpreted taking into account tumor biology and aggressiveness of the surgery

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17
Q

How does incomplete margins affect mast cell tumor survival time

A

Incomplete is about 5x worse prognosis
Complete- median survival time of 54 months while incomplete is 11 months

18 month survival- complete: 69%
18 month survival-incomplete: 14%

will grow back and likely be more aggressive

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18
Q

What is palliative surgery

A

Increase quality of life, not necessarily quantitiy
ex:
-Ulcerated tumor with distant mets
-HSA/splenectomy
-OSA/amputation only

Weigh risk / benefit

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19
Q

Cytoreductive/debulking surgery

A

more common than planned
often just a big biopsy if no adjuvant treatment
Helps other modalities (if you can get down to microscopic)
-Benefits RT <hypoxic> dosimetry
-Benefits chemo (Amp with OSA)
-Benefits immunotherapy (melanoma)</hypoxic>

Avoid closing tumor to tumor

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20
Q

Animals most get the same cancer drugs that humans get except

A

-Lower doses
-Fewer drugs given together

Less than 1/3 of patients experience unpleasant side effects from chemotherapy

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21
Q

Less than _____ of patients experience unpleasant side effects from chemotherapy

A

1/3

5% or less experience a severe side effect but most are fixed in 24-72 hours
Risk of chemotherapy related fatality is less than 1 in 200

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22
Q

Should unpleasant side effects of chemotherapy drugs occur then

A

doses can be reduced, drugs can be substituted or additional medications dispensed
these changes are effective 90% of the time

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23
Q

Whats up with hair loss with chemotherapy

A

certain breeds of dogs (the so-called- non-shedding breeds) can lose a large amount of hair
-Nonpainful
-Non itchy
-Will regrow upon cessation of chemotherapy
-Dogs dont have the body imaging concerns

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24
Q

Why do most dogs not have hair loss with chemotherapy

A

chemotherapy drugs target rapidly dividing cells
only 1/3 of dog’s hair follicles are growing at a time

-areas that are shaved might take longer to grow back
but wont get bald (unless the non-shedding breeds as they have continuously growing hair like people do)

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25
Q

Almost all chemotherapy treatments is

A

outpatient - very unusual to have overnight treatment
most is half hour or less

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26
Q

Why is most chemotherapy outpatient procedures

A

-Most are bolus or short infusion
-Many protocols involve a series of treatments followed by a period of careful observation. Continuous indefinite chemotherapy is not usual

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27
Q

What should you tell owners if they say “I dont want my family and other pets to be contaminated”

A

Urine and feces pose a minimal risk to owners- few drugs are excreted for longer than 48-72 hours

practice common sense (wear gloves when handling urine or feces) is usually sufficient

normal daily interactions (grooming, playing, petting, handling food and water bowls) pose no real risk

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28
Q

What is a substantial risk with chemotherapy

A

Risks to the staff
need to have:
-dedicated waste stream
-closed containment system
-personal protective equipment
-spill kit with dedicated staff training
-USP800

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29
Q

What do you say to a client that says “Isnt she too old for treatment”

A

Most of the patients we treat with cancer are older pets
-stats regarding treatment effectiveness, survival and tolerability are usually generated in a population of older patients

Current quality of life and concurrent illness is more important *

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30
Q

Is chemotherapy an all-or-nothing proposition

A

For many tumor types, a spectrum of treatment options may be available, depending on owner availability and finances

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31
Q

Standard response criteria: Complete disappearance of all measurable disease

A

CR (Complete Response)

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32
Q

Standard response criteria:
>50% reduction in volume of all disease (>30% reduction in diameters) no new lesions

A

PR (Partial response)

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33
Q

Standard response criteria:
<50% reduction, <25% increase in volume of all disease

A

SD (stable disease)- can be a successful treatment option in some late-stage cancers

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34
Q

Standard response criteria:
>25% increase in volume (>20% increase in diameters)

A

PD (progressive disease)

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35
Q

Prednisone has a direct anti-tumor effect against what cancers

A

1) Lymphoma / lymphoid leukemia
2) Multiple myeloma/ other plasma cell tumors
3) Mast cell tumor

most others - not useful and potentially harmful for most other cancers
used NSAIDs or narcotics for pain, appetite stimulants, antiemetics

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36
Q

Prednisone can control clinical signs in what cancers

A

-Insulinoma (hyperglycemia)
-CNS tumors (edema and swelling leading to deficits)
-Paraneoplastic hypercalcemia

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37
Q

Prednisone for palliation can be useful for lymphoma, multiple myeloma, and mast cell tumors but ___________________

A

most others - not useful and potentially harmful for most other cancers
used NSAIDs or narcotics for pain, appetite stimulants, antiemetics

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38
Q

radiation therapy of incompletely resected tumors (STS, ISS, MCT SCC, perianal, CNS, dental)

A

Adjuvant radiation treatment

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39
Q

Radiation therapy can be used for the incomplete resection of which tumors

A

1) Soft tissue sarcoma (STS)
2) Injection site sarcoma (ISS)
3) Mast Cell Tumor (MCT)
4) Squamous cell tumor (SCC)
5) Perianal
6) CNS
7) Dental

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40
Q

radiation treatment to render tumor more amenable to surgery

A

neoadjuvant radiation therapy

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41
Q

radiation therapy is primary therapy to what tumors

A

1) Nasal
2) Some CNS
3) Dental

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42
Q

Uses of radiation therapy

A

1) Adjuvant to resection
2) Neoadjuvant to render tumors more amenable to surgery
3) Primary therapy for some tumors
4) Palliation of pain, swelling, etc (OSA, melanoma, certain LSA, thymoma)

43
Q

T/F: animals receiving radiation therapy experience significant systemic illness (nausea, letargy)

A

False- RT is a local treatment modality
Systemic side effects are rare (anesthesia gives the side effects)

44
Q

T/F: Animals receiving radiation therapy develop horrible radiation burns

A

True- varying degrees of local sun-burn like reaction can occur depending on the location, protocol, and individual

often fairly mild, usually starts last week of treatment, disappears within 2-4 weeks

45
Q

Radiation therapy burns often disappear by

A

often fairly mild, usually starts last week of treatment, disappears within 2-4 weeks

46
Q

Do animals receiving radiation therapy become radioactive

A

No- Standard radiation therapy in dogs is external beam, the radiation used is no different than regular x-rays, except higher energy

47
Q

veterinary radiation therapy requires

A

1) multiple general anesthesias (or heavy sedations)
2) often some time in hospital (for practical reasons)
3) A lot of money
palliative is 1,500-6,000
curative: 6,500-15,000

48
Q

What is the goal of a biopsy

A

to obtain a diagnostic sample while limiting morbidity, limiting potential extension and avoid interference with future treatments

49
Q

Why might you biopsy in oncology

A

-appropriate prospective planning
-take advantage of several modalities
-Goldilocks treatment- not too little, not too much, just enough
-Limit morbidity
-hopefully improve overall ouctome
-and at all costs, avoid a whoops moment

50
Q

How should you prepare for biopsy

A

1) Prospective planning
-Timing with imaging
-Placement of tract (tension lines, definitive Sx)
-Use simplest technique first
-FNA, large gauge FNA, needle core, incisional, excisional

2) Be aware and counsel owners on limitations/ error rate

3) Complications- hematoma, SSI, exophytic tumor growth

4) Diagnostic utility

51
Q

would doing this test change what you do

A

diagnostic utility

52
Q

What are the limitations of FNA cytology

A

No information on structure of tumor and therefore grade or benign/malignant

53
Q

What is the diagnostic utility of FNA cytology

A

close to 100%

54
Q

With deeper tumors, what can you use with FNA cytology

A

ultrasound for image guidance

55
Q

FNA cytology is good for

A

round cell tumors, melanoma, and lipoma

56
Q

Needle-core or Tru-Cut

A

14-15g (4-6 samples)
can use image guidance (US or CT)
if need quicker diagnosis can take tissue and make squash prep

57
Q

What are the limitations of needle-core or True-cut

A

-size of tumor that is amenable
-May penetrate naive tissue or plane
-Risk to procedure (bleeding, air leak)

58
Q

What do you need to consider when doing open biopsy

A

make the cut parallel to the tension lines- keeps options open for definitive and reduces risk of adding complexity

need flat pattern

make sure to keep clear, accurate surgical notes on where, how, which planes, etc.

59
Q

Incisional biopsy is possible to do under

A

sedation and local anesthesia, depends on patient

60
Q

When doing incisional biopsy, how should you make your cuts

A

deep and narrow - need an edge or normal and abnormal

you need basement membrane present

61
Q

a group of abnormal cells that appear cancerous under a microscope but have not spread beyond where they first formed in the body, ie broken through the basement membrane

A

carcinoma in situ

62
Q

you should absolutely never do an excisional biopsy on

A

injection site sarcoma (cat)

-do FNA instead

63
Q

What are the criteria to do exicisional biopsy

A

1) Have curative intent resection option (bigger margins later)
2) High suspicion that it is benign
3) Palliation

64
Q

For biopsy you should never

A

place a drain or tension relieving

65
Q

When doing general biopsy, what needs to be included in the definitive plan

A

placement of tract

66
Q

What should you do when doing bone biopsy

A

-image guidance (ultrasound)
follow same pattern- small gauge FNA first, larger needle, then core (Jamshidi), finally open
-post biopsy radiographs or fluoroscopy

67
Q

Injection site sarcoma 3-2-1

A

mass is present, at least 3 months since the injection
swelling/mass is greater than 2cm
and has increased in size in the last 30 days
-do an FNA (never an incisional biopsy)

68
Q

What is told in pathology examination

A

1) Neoplasia vs non-neoplasia
2) Benign vs malignant
3) Histotype or even subtype (IHC or ICC)
4) Grade*
5) Margins **

always ask if this makes sense

69
Q

What should you so when the pathology report doesnt make sense

A

1) Call pathologist or email
-Resection
-IHC or other special stains
-Reaffirm the history, site, method, PE
-Second opinion or “relook”

2) Repeat biopsy

70
Q

What are the roles of surgical oncologist

A

1) Surgeon
2) Long term management of patients
3) Clinical and translational research
4) Develops and supervises clinical trials

71
Q

What are the 7 Halsted principles

A

1) Aseptic technique
2) Gentle tissue handling
3) Meticulous hemostasis
4) Preserve blood supply
5) Eliminate dead space
6) Accurate tissue apposition
7) Minimal tension

72
Q

What are possible complications of doing biopsy

A

hematoma
SSI
exophytic tumor growth

73
Q

From least invasive to invasive, rank the different biopsy principles

A

1) FNA
2) Large gauge FNA
3) Needle Core
4) Incisional
5) Excisional

74
Q

What should you do prospectively for planning biopsy

A

1) Timing with imaging
2) Placement of tract (tension lines, definitive sx)
3) use simplest technique early
4) Be aware and consel owners on limitations/error rate
5) complications- hematoma, SSI, exophytic tumor growth
6) Diagnostic utility?

75
Q

Why is hemostasis very important when doing biopsy

A

bleeding could potentially drag cancer cells deeper, expanding field

76
Q

a bud of cancer cells that is separate from the main mass
present in some high grade tumors

A

satellite tumor

77
Q

when the plane of resection is within normal tissues
higher chance for complete resection

A

Wide Resection

78
Q

when plane of resection is within the tumor reactive zone
high risk of microsopic disease

A

Marginal Resection

79
Q

What do you do if you cant get 2cm deep to the tumor on your resection because it is up against the first fascia plane

A

include that there is a barrier to tumor invasion

80
Q

With marginal resection, there is a high risk for

A

microscopic disease

81
Q

the tissue plane of dissection, which is continuous with what remains in wound bed

A

Surgical margin

82
Q

You should never place a drain when you have a

A

planned marginal resection with high risk of local recurrence because there is a higher chance of microscopic disease and youre only going to expand your field

83
Q

You should only consider a drain when

A

1) Wide and youve used a flap
2) You know there is a high risk for a seroma and a drain is the lesser of the two evils

84
Q

If you are going to use a drain, what system is preferable

A

closed systems
-exit close to suture line with no need for tunneling
-exit point either in treatment field or close enough to be treated or removed

85
Q

What tells you that you have a high risk for a seroma and should probably place a drain

A

Wide resection
1) Radiation therapy
2) High motion area

86
Q

What is the risk of suturing deep layers of fat and using walking sutures when placing a drain

A

1) Painful
2) Risk taking out a vessel and the flap dies

87
Q

What should you do when placing a drain after surgical resection

A

1) Closed systems
2) Do not suture deep layers of fat
3) Do not place walking sutures

88
Q

What drain has the potential to extend your field?

A

Penrose drain

89
Q

What factors influence the risk of seroma formation

A

1) Lymph node/ventral neck
2) High motion areas
3) Inguinal area
4) Pre-op radiation therapy

90
Q

What should you tell the owner to do to prevent seroma formation

A

Strict rest
Ice packing
Surgisox (compression bandage)

91
Q

There is no risk of drain/seroma if you have

A

1) Complete resection
2) Clean resection
3) Negative resection

but one drain or a badly placed one in an incomplete or dirty resection is trouble

92
Q

With reconstruction, primary closure is always the first option and achievable in most cases but we should never let

A

complicated reconstruction limit our chances for local cure

93
Q

Axial pattern flap

A

a flap is based on a known blood vessel, artery and vein

axial pattern flap is based on a named vessel

94
Q

What should you never use in an unknown margin

A

releasing incisions- because it expands our treatment field

95
Q

Should you do releasing incisions

A

NO- it expands treatment field

96
Q

What should you consider when doing a flap

A

1) Always do with a wide resection
2) Change your gloves and instruments between flap and resection
3) Raise flap first, close donor site, then do resection

97
Q

You should only consider a flap when doing

A

a wide resection (never marginal)

98
Q

The quality of the pathology report is directly related to

A

quality of the speciment

99
Q

Why do we use tissue inking

A

alert pathologist to an area of interest
1) Cut edge
2) Deep margin
can use different colors for different areas only to alert pathologist

100
Q

What should you do to maintain tumor orientation when submitting a tumor

A

1) Ink cut edge and deep margins
2) Suture deep plane to skin to maintain orientation
3) Tend a picture
4) Send whole tumor

101
Q

Where does changing gloves and instruments make a difference

A

1) Moving from site to site
2) Tumor ruptures in hand
3) High risk of seeding (ie urothelial carcinomas or thymoma)
4) Flap

102
Q

Where does changing gloves and instrument not make a difference

A

1) Wide or marginal
2) Ruptured spleen

103
Q
A

ONCOLOGY & CC (6 decks)

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