Principles of Surgical Oncology Flashcards
Surgery for biopsy - Definition
Retrieval of cells or tissue from the tumour to allow -
Diagnosis & prognosis (grading and staging)
Indication of appropriate therapy
The owner to make a decision about treatment
Biopsy of: T, N or M
- T: 1y tumour
- N: Lymph node
- M: Metastases
when to biopsy
If the treatment plan would be changed by the outcome - Type + extent of treatment (Sx vs chemotx vs radiotx), (conservative vs aggressive)
If the owner’s decision to treat would be changed - Tumour type & grade, Clinical stage & Prognosis
If lesion is in a “difficult” area - Head & neck, Distal limb
when not to biopsy
treatment plan would not be changed -Mammary masses, single large lung masses
No change in owner’s willingness to treat - Chest wall/limb sarcoma resection
biopsy is difficult - CNS mass lesions, Thyroid tumours, Small intestine tumours
key steps in tumour biopsy
biopsy at correct time i.e. early in the course of the disease
use correct technique
submit sample to experienced
read report carefully + speak to the pathologist
Reason for biopsy - Subcutaneous mass on the flank
Lipoma vs Mast cell tumour vs Soft tissue sarcoma
Differ in - Surgical margin + Prognosis
Reason for biopsy - Large cranial mediastinal mass
thymoma or lymphoma?
Differ in - Necessity for surgery + Prognosis
Reason for biopsy - Mandibular mass
Acanthomatous epulis vs fibrosarcoma vs melanoma
Differ in - Surgical margins + Prognosis (cure vs palliation)
information from biopsy
Definitive diagnosis of neoplasia
Aggressiveness of neoplasia (Benign/malignant)
Cytologic type of neoplasia (Round cell vs epithelial vs mesenchymal)
Histologic features (histological type +Grade of tumour)
Evaluation of metastases
assessment of margins
considerations for biopsy
Pre-biopsy considerations Regional considerations Biopsy technique Which part of lesion to biopsy How to submit samples How to read the histology report
Biopsy Techniques
needle incisional excisional core punch
prophylactic surgery
Reduces the incidence of a particular tumour
Reduces the recurrence rate after treatment
Tissue removed may be - normal tissue: gonads or Abnormal tissue: pre-malignant change
Indications - Increased risk of tumour development, Confirmed dx of pre-malignant change or neoplasia, Surgical excision not associated with high morbidity
definitive excision
The use of surgery as the sole treatment, without
adjunctive therapy, to achieve an outright cure
The removal of all the tumour at one surgery
Indications - Localised disease, Regional metastases (occasionally)
N.B. Surgery may not remove 100% of tumour cells The immune response may remove the remainder
advantages of surgery
Immediate cure Not carcinogenic No local toxic effects Not immunosuppressive Better for large masses
disadvantages of surgery
Local cure only
Change in cosmesis
Change in function
principles of surgical excision
establish a diagnosis by biopsy + plan surgery
perform surgery early in course of disease
1st surgery high highest success rate
adequate margins needed in 3 dimensions
margins of excision shouldn’t be compromised by concerns with closure
planning surgery
Histological diagnosis
Extent of local disease
Presence of local or distant metastasis
nutritional status of the patient
correct surgery 1st time
Untreated tumours have normal regional anatomy which facilitates removal
Recurrent tumours may have seeded into previously non-involved tissue planes making it difficult to predict tumour extension, hence a wider resection is required
most active & invasive parts of the tumour are at the periphery; incomplete excision leaves the aggressive cells behind
less normal tissue after previous surgery making closure more difficult
post-operative changes
Cosmetic appearance vs function
cosmesis is our concern, not the patient’s
explain with pictures & contact with other clients
common reasons for failure of definitive tumour excision
fail to plan surgery, usually due to lack of biopsy
fail to stick to plan, usually due to closure concerns
margins of excision
“Normal” tissue around tumour infiltrated by tumour cells
Finger-like projections
Satellite metastases
“Skip” metastases
Removal of the tumour & a margin of normal tissue
The nature of the margin depends on the tumour
Margin given as - Distance e.g. 1-3 cm, Natural barrier to tumour growth e.g. fascia (esp sarcomas)
pseudocapsule
A zone of compressed tissue around the tumour This zone contains viable tumour cells
Do not enter the pseudocapsule - Do NOT “shell-out”
local excision
Tumour removed through natural capsule or immediate boundaries
Indications: Benign tumours & no local invasion, lipoma, histiocytoma, sebaceous adenoma
Preservation of adjacent tissue
Thyroid adenoma, CNS
Contraindications - Local invasion, Malignancy
wide local excision
Tumour removed with substantial margin of normal tissue
Indications: Benign tumours/local invasion, Malignancy/limited local invasion
Contraindications - More invasive malignancies, Higher grade tumours
radical excision
Margins extend into fascial planes undisturbed by tumour growth
Indications - Malignancy & local invasion
4 types of radical excision
Radical local excision
compartmental excision
Muscle group excision
Amputation
radical local excision
Tumour removed with extensive margins of tissue
including 1 or 2 fascial planes beyond gross tumour
Invasive sarcomas of the abdominal or chest wall - Chest or abdominal wall resection
Invasive carcinoma of the nasal planum - Nasal planum resection & premaxillectomy
Invasive tumours involving eyelids - Excision of eyelids & orbital contents
Invasive orbital/periorbital tumours - Orbitectomy
compartmental excision
Tumour removed in an intact anatomic compartment
Indications - Invasive tumours involving limbs, Invasive tumours on the trunk
muscle group excision
Tumour removed along with the muscle it involves
Indications - Small tumours involving muscle bellies, No breach of fascial plane, or breach which is
excised
amputation
Tumour removed with the entire limb
Indications - Large tumours - other method not possible, If radical excision impairs function - bone/joint excision, Management of recurrences - disturbed fascial planes
inadequate excision
leads to: Local recurrence, Persistence of tumour & increased chance of metastasis
Usually due to - Inadequate surgical plan (failure to biopsy), Failure to follow surgical plan (concerns re closure)
Options - Re-operate – wider margins, Adjunctive therapy, Radiotherapy, Chemotherapy
preparation for histology
Anatomically relevant - Lay out as in vivo +/- sutures
Indicate margins of interest -Closest to tumour
Methods of marking margins - Suture tag, Paint with ink, Draw a picture to orientate
Provide a history - Relevant & detailed
evaluation of the tissue
Not optional item
If worth removing - worth histopathology
not sole way of identifying the tumour - i.e. care with excisional biopsy – incomplete excision
excisional histology info
Histological type of tumour - Confirms pre-op knowledge of tissue type
Histological grade of tumour - Mitotic index, differentiation, necrosis
Regional lymph node status - access
Staging of disease
Margins – adequacy of excision, Predicts local recurrence
Vascular or lymphatic invasion - Predicts distant metastasis
evaluations of margins
False negative - Tumour present at margins - but not the one examined
False positive - Tumour present - but edge examined is not a margin
Specimen incorrectly oriented
cytoreductive surgery - define
The planned incomplete removal of the tumour
To improve the efficacy of other modalities
cytoreductive surgery - indications
Essential structures (CNS tumours) Surgical management of recurrences Unknown tumour borders Local recurrence likely (SA distal limb) Highly malignant tumours Vaccine-associated sarcomas
Adjunctive therapies - pre-op therapy
To reduce tumour bulk prior to surgery e.g. sarcoma
Adjunctive therapies - intra-op therapy
To gain access to tumours e.g. bladder tumour
Adjunctive therapies - post-op therapy
treat small no. of rapidly proliferating, well-oxygenated cells e.g. mast cell tumour
Adjunct Treatments for Cancer
chemotherapy radiation therapy immunotherapy hyperthermia photodynamic therapy
chemotherapy
treat invasive or metastatic tumours not completely removed by surgery
used before or after surgery
debulk at least 90% of the tumour
potential complications-delayed wound healing, vomiting, diarrhoea, nephrotox., bone marrow
suppression
radiation therapy
fractions of radiation directed at the tumour
used before, during or after surgery
shrink the tumour before or destroy any remaining cells after surgery
potential for early or late moist desquamation or ulceration of tissues
immunotherapy
elements of the immune system used against
tumours
interleukins, cytokines, interferons, CSF, monoclonal antibodies
rapidly developing area of research to find very specific effect on tumours
hyperthermia
hyperthermia used to destroy tumour cells that are sensitive to temperature changes
used locally or systemically
often combined with chemo. or radiation therapy
currently not a very practical method
photodynamic surgery
the use of various wavelengths of light to destroy tumour cells
sensitising agents given to the patient are taken up by tumours cells
the tumour is exposed to light causing a reaction with the sensitising agent
the result is destruction of tumour cells
Palliative surgery - Definition
Surgery performed to improve quality of life, for pain relief, improved function of the affected part, or to eliminate life-threatening complications
Consider balance between potential gain vs morbidity
palliative surgery - indications
Tumour with metastasis
Complete excision impossible
palliative surgery - examples
Limb amputation for osteosarcoma Splenectomy for haemangiosarcoma Placement of a cystostomy catheter for TCC Removal of ulcerated mammary tumours Mandibulectomy for oral melanoma Pericardectomy
