Principles of Surgical Oncology

Question 1

Surgery for biopsy - Definition

Answer 1

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

Question 2

Biopsy of: T, N or M

Answer 2

• T: 1y tumour
• N: Lymph node
• M: Metastases

Question 3

when to biopsy

Answer 3

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

Question 4

when not to biopsy

Answer 4

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

Question 5

key steps in tumour biopsy

Answer 5

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

Question 6

Reason for biopsy - Subcutaneous mass on the flank

Answer 6

Lipoma vs Mast cell tumour vs Soft tissue sarcoma

Differ in - Surgical margin + Prognosis

Question 7

Reason for biopsy - Large cranial mediastinal mass

Answer 7

thymoma or lymphoma?

Differ in - Necessity for surgery + Prognosis

Question 8

Reason for biopsy - Mandibular mass

Answer 8

Acanthomatous epulis vs fibrosarcoma vs melanoma

Differ in - Surgical margins + Prognosis (cure vs palliation)

Question 9

information from biopsy

Answer 9

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

Question 10

considerations for biopsy

Answer 10

Pre-biopsy considerations 
Regional considerations 
Biopsy technique 
Which part of lesion to biopsy 
How to submit samples 
How to read the histology report

Question 11

Biopsy Techniques

Answer 11

needle
incisional 
excisional
core
punch

Question 12

prophylactic surgery

Answer 12

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

Question 13

definitive excision

Answer 13

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

Question 14

advantages of surgery

Answer 14

Immediate cure 
Not carcinogenic 
No local toxic effects 
Not immunosuppressive 
Better for large masses

Question 15

disadvantages of surgery

Answer 15

Local cure only
Change in cosmesis
Change in function

Question 16

principles of surgical excision

Answer 16

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

Question 17

planning surgery

Answer 17

Histological diagnosis
Extent of local disease
Presence of local or distant metastasis
nutritional status of the patient

Question 18

correct surgery 1st time

Answer 18

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

Question 19

post-operative changes

Answer 19

Cosmetic appearance vs function
cosmesis is our concern, not the patient’s
explain with pictures & contact with other clients

Question 20

common reasons for failure of definitive tumour excision

Answer 20

fail to plan surgery, usually due to lack of biopsy

fail to stick to plan, usually due to closure concerns

Question 21

margins of excision

Answer 21

“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)

Question 22

pseudocapsule

Answer 22

A zone of compressed tissue around the tumour This zone contains viable tumour cells
Do not enter the pseudocapsule - Do NOT “shell-out”

Question 23

local excision

Answer 23

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

Question 24

wide local excision

Answer 24

Tumour removed with substantial margin of normal tissue
Indications: Benign tumours/local invasion, Malignancy/limited local invasion
Contraindications - More invasive malignancies, Higher grade tumours

Question 25

radical excision

Answer 25

Margins extend into fascial planes undisturbed by tumour growth Indications - Malignancy & local invasion

Question 26

4 types of radical excision

Answer 26

Radical local excision compartmental excision Muscle group excision Amputation

Question 27

radical local excision

Answer 27

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

Question 28

compartmental excision

Answer 28

Tumour removed in an intact anatomic compartment | Indications - Invasive tumours involving limbs, Invasive tumours on the trunk

Question 29

muscle group excision

Answer 29

Tumour removed along with the muscle it involves Indications - Small tumours involving muscle bellies, No breach of fascial plane, or breach which is excised

Question 30

amputation

Answer 30

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

Question 31

inadequate excision

Answer 31

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

Question 32

preparation for histology

Answer 32

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

Question 33

evaluation of the tissue

Answer 33

Not optional item If worth removing - worth histopathology not sole way of identifying the tumour - i.e. care with excisional biopsy – incomplete excision

Question 34

excisional histology info

Answer 34

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

Question 35

evaluations of margins

Answer 35

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

Question 36

cytoreductive surgery - define

Answer 36

The planned incomplete removal of the tumour | To improve the efficacy of other modalities

Question 37

cytoreductive surgery - indications

Answer 37

``` Essential structures (CNS tumours) Surgical management of recurrences Unknown tumour borders Local recurrence likely (SA distal limb) Highly malignant tumours Vaccine-associated sarcomas ```

Question 38

Adjunctive therapies - pre-op therapy

Answer 38

To reduce tumour bulk prior to surgery e.g. sarcoma

Question 39

Adjunctive therapies - intra-op therapy

Answer 39

To gain access to tumours e.g. bladder tumour

Question 40

Adjunctive therapies - post-op therapy

Answer 40

treat small no. of rapidly proliferating, well-oxygenated cells e.g. mast cell tumour

Question 41

Adjunct Treatments for Cancer

Answer 41

``` chemotherapy radiation therapy immunotherapy hyperthermia photodynamic therapy ```

Question 42

chemotherapy

Answer 42

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

Question 43

radiation therapy

Answer 43

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

Question 44

immunotherapy

Answer 44

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

Question 45

hyperthermia

Answer 45

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

Question 46

photodynamic surgery

Answer 46

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

Question 47

Palliative surgery - Definition

Answer 47

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

Question 48

palliative surgery - indications

Answer 48

Tumour with metastasis | Complete excision impossible

Question 49

palliative surgery - examples

Answer 49

``` Limb amputation for osteosarcoma Splenectomy for haemangiosarcoma Placement of a cystostomy catheter for TCC Removal of ulcerated mammary tumours Mandibulectomy for oral melanoma Pericardectomy ```