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Y4 SA - Oncology > Principles of oncology surgery > Flashcards

Principles of oncology surgery Flashcards

1
Q

What do you need to have before you can treat neoplasia?

A

Histological diagnosis - predict tumour behaviour
Tumour stage
A PLAN!

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2
Q

List the role of surgery in managing cancer

A
  • Prophylaxis
  • Biopsy for diagnosis
  • Definitive/curative surgery
  • Palliative treatment
  • Cytoreduction followed by medial oncological treatment: Chemotherapy, Radiation therapy
  • Treatment of metastatic disease
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3
Q

How is castration used prophylactically for cancer?

A

Prevents testicular neoplasia
Does NOT prevent prostatic neoplasia

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4
Q

How is ovariohysterectomy/ovariectomy used prophylactically for cancer?

A

Prevents ovarian and uterine neoplasia
Reduces the risk of developing mammary neoplasia

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5
Q

How can surgery be used for cancer dagnosis?

A

FNA - cytology
Incisional biopsy - histopathology
Excisional biopsy - histopathology

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6
Q

What is an FNA?

A

Aspiration of cells following needle insertion into a solid mass, lymph node or organ

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7
Q

How does the success of FNA exfoliation vary?

A

Good: e.g. epithelial masses, MCTs
Poor: mesenchymal masses (e.g. fibrosarcoma)

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8
Q

What are the advantages of FNA?

A

Invasive, faster procedure & interpretation, less expensive

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9
Q

Describe an incisional biopsy

A
  • Part of a mass is removed + submitted for histopathology
  • Biopsy multiple areas if varied appearance
  • Position should not compromise definitive surgery
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10
Q

Describe an incisional biopsy for soft tissue masses

A

Centre may be necrotic (non-representative)
Deep biopsy, include ”normal” tissue margin

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11
Q

Describe an incisional biopsy for bone tumours

A

Peripheral bone may be reactive (non-representative)
Ensure deep biopsy

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12
Q

What is an excisional biopsy

A
  • The whole mass is removed + submitted for histopathology
  • Benign masses (confirmed on cytology/previous incisional biopsy)
  • Small masses, if wide margins anatomically achievable
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13
Q

When should an excisional biopsy be avoided?

A

As first line surgery without prior diagnosis

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14
Q

Describe the 3 main ‘layers’ of a tumour

A

Pseudocapsule = tumour = compressed neoplastic cells of tumour periphery
Reactive zone = healthy, reactive host cells
Normal tissue

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15
Q

What is the surgical margin?

A

The region of tissue excised as part of an excisional biopsy

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16
Q

Describe the metric approach for margins of excision

A

Margin of tissue excised, measured by distance from the primary tumour in three dimensions (lateral & deep margins)

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17
Q

Describe the barrier approach for margins of excision

A

Use of tumour resistant anatomic boundaries (fascia, periosteum, cartilage, air) to create an excisional margin

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18
Q

Which tissues do not act as barriers?

A

Fat
Subcutaneous tissue
Muscle
Parenchymal tissue

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19
Q

Describe the hybrid metric/barrier approach for margins of excision

A

e.g. 2cm lateral margins, 1 deep intact fascial plane

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20
Q

Describe a wide margin excision type

A

All neoplastic tissue excised with a margin of microscopically normal tissue
Tumour and Pseudocapsule not entered
- no residual tumour left

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21
Q

Describe the radical excision method

A

En bloc excision of the tissue/organ compartment e.g. amputation
- result = no residual tumour

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22
Q

What are the two methods of curative intent surgery?

A

Radical excision
Wide excision

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23
Q

What are the +ves and -ves of curative intent surgery?

A

+ves = complete removal of neoplastic tissue
-ves = greater surgical ‘dose’
Incorrect margins -> wider area of tissue contaminated so surgical revision or adjunct treatment may be required

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24
Q

What are the +ves and -ves of marginal excision surgery?

A

+ves = lower surgical dose
-ves = margin may or may not be complete
Incomplete surgical margin -> cytoreductive
so surgical revision or adjunct treatment may be required

25
Q

Describe cytoreductive surgery, including its +ves and -ves

A

Debulking
+ves = lower surgical dose
-ves = neoplastic tissue will remain
Recurrence may be rapid - plan adjunctive chemo/RT

26
Q

What should be done in cases of inoperable/poorly responsive to surgery?

A

Consider chemotherapy or radiation?
Palliative care

27
Q

What type of excision to perform is determined by what factors?

A
  • What is the intent (aim/likely achievement) of surgery?
  • Type of neoplasia: origin tissue, benign or malignant, grade (if known)
  • Biological behaviour: risk and RATE of invasion/ metastasis/recurrence
  • Tumour staging
  • Tumour size
  • Tumour location : local anatomy, availability of appropriate margins, wound closure options
  • Surgical morbidity: risks, complications, effects on local anatomy
  • Patient suitability: co-morbidities, anaesthetic risk, temperament
  • Other treatment options? How responsive is this tumour to chemo/ radiation treatment?
  • Prognosis
  • Owner considerations
28
Q

Why does the first surgery performed have the best chance of complete tumour removal?

A

Normal surrounding anatomy -> excision can be wider/more aggressive

29
Q

Why is revision surgery more complex?

A
  • Disrupted local anatomy- surgery more challenging
  • Tumour seeding: previously unaffected tissue planes may now be affected
  • Less tissue for wound closure
30
Q

What are the main problems with incomplete tumour excision?

A
  • Increases tumour biological activity -> rapid local tumour recurrence
  • Decreases overall survival time
31
Q

When using wide excisions the amount of resected tissue depends on which factors?

A
  • Tumour type and grade
  • Tumour size
  • Biological behaviour
  • Local tissue barriers/fascial planes
32
Q

What are the recommended margins for benign masses?

A

1cm lateral and deep margins

33
Q

What are the recommended margins for most carcinomas and low grade soft tissue sarcomas?

A

1cm lateral
1 deep intact facial plane

34
Q

What are the recommended margins for high grade soft tissue sarcomas?

A

2-3cm lateral
One deep intact facial plane

35
Q

What are the recommended margins for feline injection site sarcomas?

A

3-5cm lateral
2 deep intact facial planes

36
Q

When using radical and wide excisions what methods/principles can be applied to maximise the chance of surgical cure

A
  • Know what the tumour type is (pre-operative incisional biopsy)
  • Know what margin is required for curative intent surgery of this tumour type
  • Review the local anatomy
  • Plan the resection and reconstruction of surgery BEFORE we start operating
  • Have a plan B (and C) for reconstruction
  • Clip and prepare a large area
  • Position the patient sensibly
  • Use a surgical marker pen to outline the planned resection
  • Resect the tumour “en bloc”
  • Lavage surgical site
  • Change gloves and instruments once the tumour is resected to reduce tumour seeding
  • Follow Halstead’s surgical principles to improve wound healing!
37
Q

In which circumstances is a margin excision technique appropriate?

A

Removal of a lipoma (curative)
Preservation of key local anatomy
Removal of a malignant tumour as part of multimodal therapy

38
Q

What are the aims of palliative surgery?

A
  • To improve quality of life in the short term
  • Removal of tumour burden may restore or maintain quality of life until euthanasia is inevitable
    e.g. hopeless prognosis due to early metastasis
    e.g. patient has an unrelated but life limiting disease
39
Q

What should happen following surgical excision of a tumour?

A
  • Submit ALL excised tissue for histopathology
  • For radical, wide and marginal excisions request an assessment of the margins
  • Consider “inking” the deep margin of the excised tissue to aid margin assessment
  • Consider placement of sutures to help orientate the excised tissue
40
Q

What information should be included in histopathological reports?

A
  • Tissue diagnosis
  • Markers of malignancy
  • Margin assessment
  • Grade? e.g. cutaneous mcts, mammary carcinoma, soft tissue sarcomas
  • Prognosis
  • Further advised tests (e.g. additional block cuts, special stains, immunohistochemistry)
41
Q

List the markers of malignancy that would be described on a histopathological report

A
  • Evidence of increased cellular activity: increased mitotic rate, abnormal mitoses
  • Abnormal cell morphology (loss of differentiation, pleomorphism)
  • Evidence of metastasis: vascular or lymphatic invasion
  • Evidence of local tissue invasion: invasion of the surgical margins, perineural infiltration
42
Q

Describe a complete surgical margin assessment histopathology result

A

No neoplastic cells within 3-5mm of the tumour margin, margins contains NORMAL tissue surrounding the tumour pseudocapsule
Benign: Curative
Malignant: Reduces risk of recurrence

43
Q

Describe a complete but narrow surgical margin assessment histopathology result

A

Neoplastic cells <3mm from the surgical margin OR margin does not contain normal tissue beyond the tumour pseudocapsule

44
Q

Describe a incomplete but narrow surgical margin assessment histopathology result

A
  • Tumour cells within the edges of the surgical margins in at least one tissue plane
  • Neoplastic cells therefore likely to remain in surgical site tissues
45
Q

How should patients be managed following an incomplete but narrow surgical margin assessment histopathology result

A

Depending on tumour type & patient:
- Monitor for recurrence
- Staged resection of the surgical wound
- Resection of the surgical scar with 1-2cm margin and histopathology
- Wide excision of the surgical wound
- Resection of the surgical scar with a 2-3cm margin and intact deep fascial plane and histopathology
- Adjunctive chemotherapy and/or radiotherapy

46
Q

What information would you want to find out on the history of a patient with a new mass

A
  • Duration
  • Changes in appearance? Growth/fluctuation, changes in texture/shape/ pigmentation/overlying or adjacent tissues
  • RATE of change (rapid vs slow)
  • Patient signalment & systemic health/co-morbidities
  • Paraneoplastic signs
47
Q

How would you examine a patient with a new mass

A

GENERAL including peripheral lymph nodes!
MASS SPECIFIC: Size (measure), location, texture, mobile or fixed to underlying/adjacent tissues, pain, evidence of secondary infection, MCTs – Darier sign.

48
Q

Describe the biological behaviour of a benign mass

A

Will not invade locally or metastasize

49
Q

Describe the biological behaviour of a carcinoma

A

Metastasis > invasion

50
Q

Describe the biological behaviour of a sarcoma

A

Invasion > metastasis

51
Q

Define tumour staging

A

Process by which the extent of disease progression from the primary site is assessed

52
Q

What do the TNM of tumour staging stand for?

A

TUMOUR: size & invasiveness
NODE: presence of local lymph node metastasis
METASTSIS: presence of distant organ metastasis (e.g., lung, liver, spleen)

53
Q

How can you investigate a stage T lesion

A
  • Measure the externally visible mass
  • Assess adjacent tissues
  • 3D imaging of the non-externally visible mass
  • Consider FNA or incisional biopsy
54
Q

How can you investigate a stage N lesion

A
  • Palpation & sizing of peripheral lymph nodes
  • Contrast CT (cCT) imaging of node size & contrast enhancement
  • FNA, incisional or excisional biopsy of lymph nodes
55
Q

How can you investigate a stage M lesion

A
  • Assessment of thorax/abdomen/skeleton
  • Thorax: 3 view inflated thoracic radiographs OR cCT
  • Abdomen: Ultrasound OR cCT
  • Skeleton: Radiographs OR cCT
  • Consider FNA or incisional biopsy
56
Q

How can you investigate a systemically neoplastic patient?

A

Identify co-morbidities, anaesthetic & drug suitability
General physical examination
Haematology, serum biochemistry, urinalysis
+/- specific tests

57
Q

Which factors may influence oncology treatment options?

A
  • Tumour biology: What might each treatment achieve?
  • Is a clean surgical margin likely? (tumour type, anatomy)
  • Is metastasis present?
  • Patient morbidity
  • What are the risks and complications?
  • Effect on surrounding tissues?
  • Patient mortality: What is the expected survival time?
  • Owner expectations & commitment
58
Q

What information needs to be communicated with clients before a diagnosis?

A
  • Why should we investigate?
  • How should we investigate?
  • What are the practicalities? Impact on patient? Financial costs?
  • If NOT investigating now…set a short term re-assessment
59
Q

What information needs to be communicated with clients after a diagnosis?

A
  • Cancer type: biological behaviour: Benign? Malignant?
  • +/- Surgical margins - Complete or incomplete?
  • Any further tests required? E.g. special stains
  • Prognosis?
  • Recurrence? Metastasis? Average survival?
  • Follow up monitoring ?
  • Follow up treatment?

Y4 SA - Oncology (12 decks)

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