Principles of Surgical Oncology

Question 1

Why are recurring tumours after initial surgery more locally invasive? (2)

Answer 1

-Altered vascularity
- Local immune response

Question 2

What are the 4 categories in Enneking’s classification?

Answer 2

1. Intracapsular debulking
2. Marginal
3. Wide
4. Radical

Question 3

What was the basis of Enneking’s classifcation?

Answer 3

The macroscopic relationship of the margin to the tumour and its pseudocapsule.

Question 4

An intralesional margin would be obtained when..

Answer 4

the dissection passes within the lesion, which means the tumour’s pseudocapsule has been opened and violated during surgery. Either macroscopic or microscopic tumour tissue is usually left at the margins, and there may be contamination of the exposed tissue planes.

Question 5

What is the most common intralesional procedure?

Answer 5

A diagnostic incisional biopsy or by subtotal “debulking” resection of the tumour.

Question 6

What is cytoreductive surgery?

Answer 6

the incomplete removal of a tumour

Question 7

When is cytoreductive surgery a practical consideration? (3)

Answer 7

Prior to:
Cryosurgery
Chemo
Radio

Question 8

When is cytoreductive acceptable as a treatment?

Answer 8

BENIGN conditions (otherwise need to be followed with other tx.)

Question 9

What does a marginal margin result from?

Answer 9

a procedure in which the tumour is removed through the pseudocapsule or “reactive zone” around the tumour.

Question 10

When a marginal resection is performed for soft tissue sarcoma, there is a possibility of..

Answer 10

microscopic residual tumour

Question 11

Why will marginal margins be performed? (2)

Answer 11

• excisional biopsy
• close to critical structures, including nerves, vessels, and organs.

Question 12

What is a wide margin?

Answer 12

A wide margin is accomplished by a procedure in which the lesion is resected with the surrounding normal tissue.

Question 13

What is a radical margin?

Answer 13

A radical margin in achieved by a procedure in which the tumour is resected with wide margins plus the entire tissues/organ in the anatomic compartment. Radical resection is defined as the removal of a body part.

Question 14

Define wide resection

Answer 14

a tumour is resected along with surrounding normal tissue (e.g. a soft tissue sarcoma resection)

Question 15

Define marginal resection

Answer 15

a tumour removed through a pseudo capsule or reactive zone (e.g. for a tumour close to critical structures)

Question 16

Define intralesional resection

Answer 16

dissection passes within the lesion (e.g. debulking surgery)

Question 17

Define radical resection

Answer 17

tumour is removed by removing an entire body part (e.g. limb amputation)

Question 18

What surgeries are considered curative-intent surgeries? (2)

Answer 18

Wide + radical resections

Question 19

What are the oncology aims of wide/radical resections?

Answer 19

Resecting macroscopic and microscopic disease, including biopsy tracts

Question 20

Following skin/subcut incisions - what should we do with skin edges and why?

Answer 20

Protective drapes or swabs should be placed on skin edges to prevent tumour seeding.

Question 21

Why is prompt haemostasis crucial in tumour removal?

Answer 21

To prevent the release of tumour emboli into the circulation (especially for tumours with a good vascular supply, such as splenic and lung tumours)

Question 22

What should be performed to dilute residual exfoliated cells?

Answer 22

Wound lavage

Question 23

Why should drains be used sapringly in oncological surgery?

Answer 23

disrupt deep and lateral tissue planes distant to the surgical field.

Question 24

What should the surgeon do fallowing tumour excision to prevent contamination with exfoliated tumour cells?

Answer 24

Change - gloves, drapes and kit.

Question 25

In the most recent studies, how is “histologically free margins” define?

Answer 25

Both quantitatively (e.g. 4 mm) and qualitatively (e.g. normal adipose tissue).

Question 26

What lateral margins should be taken for benign tumours?

Answer 26

1cm

Question 27

What lateral margins for most malignant carcinoma?

Answer 27

1cm

Question 28

What lateral margin for STS?

Answer 28

3cm

Question 29

Lateral margins for Grade I and II MCT?

Answer 29

2cm

Question 30

What should deep margins contain?

Answer 30

1 fascial plane

Question 31

What are resistant to neoplastic invasion and area good natural tissue barrier?

Answer 31

Connective tissues, such as muscle fascia and bone

Question 32

How are lateral margins determined with modified proportional margin (MPM) approach?

Answer 32

The surgeon measures the widest diameter of the tumour and this measurement is used as the lateral margin for excision.

Question 33

Why shouldn’t tumours be “shelled out” - particular STS?

Answer 33

Surrounded by a pseudo capsule of compressed, viable neoplastic cells and a reactive zone;

Question 34

Select the tissues that provide a good natural barrier to tumour invasion.

Answer 34

Muscle fascia
Bone

Question 35

Generating tissue for histopathology involves five broad phases which might impact the pathologist’s ability to collect reliable data. They are:

Answer 35

• immediate post-excisional period;
• tissue fixation;
• trimming (sectioning of the fixed gross specimen so that tissue adequately fits into a cassette)
• histologic processing (post-fixation processing, microtomy and slide mounting);
• morphologic slide evaluation.

Question 36

How should large tumour histo samples be fixed?

Answer 36

Slice into sections more than 1 cm thick to facilitate adequate fixation, but to maintain the ability of the pathologist to orient the sample and assess margins, the slicing should not be full thickness

Question 37

How should samples be submitted to orientate pathologist with margins?

Answer 37

Mark with sutures or dye

Question 38

What information should be submitted with a histo sample? (6)

Answer 38

• Location
• Size
• Shape
• Texture
• Relationship to surrounding structures
• if required - a picture of margins in relation to site

Question 39

Prior to formalin fixation - how much does the tissue shrink by?

Answer 39

15.6%

Question 40

Why does a tumour shrink following removal?

Answer 40

myofibril contractility
tissue elasticity