Principles of Sx Onco- exam 2 Flashcards
What is one of the most crucial steps in management of the cancer patient?
Properly timed, performed and interpreted bx
When should you perform a pre-treatment biopsy?
FNA provided insufficient information and non-dx
Suspicion of false neg
Life/death decision based on results
Tumor changes sx approach
willingness of O would change based on results
Sx is in a difficult anatomical location
Tx has high morbidity
What type of biopsy is performed during pre-treatment biopsy?
Incisional biopsy
Why are pre-treatment biopsies performed?
Obtain additional information about the tumor prior to definitive tx
What types of incisional biopsy are there?
Needle core
Wedge
Punch
What type of biopsy is performed for post-treatment biopsy?
Excisional biopsy
T/F: Excisional post-op biopsy allows for a more complete picture of the disease process
TRUE
What type of tissue should be avoided for incisional biopsy?
Ulcerated/inflamed tissue
What should the orientation of incisional biopsy be in regards to tension lines?
Parallel
What are some pros to incisional biopsy?
Better planning=better chance for sx cure
Established informed consent w/ client
Appropriate implementation of neoadjuvant and adjuvant tx
What are some cons to incisional biopsy?
Two procedures ($$)
More invasive for the patient
Increased risk of local recurrence
What are the six incisional biopsy techniques?
Tru cut Punch biopsy Wedge biopsy Jameshedi/Michelle Trephine Endoscopic/Laparoscopic Specialized
What are the sizes of TruCut needles that can be used?
14 Ga
16 Ga
18 Ga
What are some pros to performing trucut biopsy?
Used on any accessible mass
Maintains structural integrity of tissue
Perfomred under sedation/local anesthesia
Obtain multiple samples
What size punch must be taken for a diagnostic punch biopsy sample?
> 6 mm
When should you NOT use punch biopsy?
For hypodermal masses- hemorrhage can occur
When is a wedge biopsy the most preferred technique?
When there is ulcerated or necrotic tissue and for deeply located mass
When should excisional biopsies be performed?
Treatment would NOT be altered by tumor type or grade
Procedure to get to mass is invasive or carries high risk (bleeding)
If the location is permissive of wide margins without compromising the potential for future re-excision
In what situation should an excisional biopsy be perfomred?
Splenectomy- don’t biopsy the spleen, just remove the entire organ so you won’t have to go back if the bx confirms malignancy
What are the specific techniques for excisional biopsy?
Prevention of tumor seeding- avoid contamination of surrounding tissue
Eliminate all dead space
DON’T PLACE A DRAIN- this allows the travel of tumor cells
What are majority of solid tumors surrounded by?
Pseudocapsule- this may contain microscopic tumor extensions or satellite populations of tumor cells
What is the classification system of surgical dosing?
Enneking system
What are the four classes of the Enneking system?
Intralesional (Intracapsular)
Marginal
Wide
Radical
When is the intralesional approach not ideal?
For malignant tumors since growth of cells would be left behind
When do you use the intralesional approach?
Lipomas
What is the order of least to most invasive tumor sx approaches?
Intralesional - Marginal - Wide- Radical
When performing a marginal approach to tumor removal, what are your margins for carcinomas, MCT, soft tissue/bone sarcomas and feline injection site sarcomas?
Carcinomas: <1 cm
MCT: <2 cm
STS/BS: <3 cm
Feline injection site sarcomas: <5 cm
What is the technique for marginal excision of a tumor?
Through the pseudocapsule or perilesional zone surrounding the tumor
What type of sx excision method would you use for tumors in these examples?
On extremities, near the eye or perianal region
Marginal tumor excision
Describe the process for wide sx excision for tumors?
Normal tissue outside the pseudocapsule
What are the lateral margins for wide tissue biopsy approach?
Carcinoma, MCT, STS, Feline injection site sarcoma
Carcinomas: > 1 cm
MCT: >2 cm
Soft tissue/bone sarcomas: > 3cm
Feline injection site sarcoma: > 5 cm
What is the minimum plane margins for soft tissue sarcoma for wide surgical excision?
1 fascial plane deep or 2 muscle planes deep
What is the minimum plane margins for MCT for wide surgical excision?
Minimum of 2-3 cm lateral margins and a fascial plane deep
What is radical surgical excision?
Entire compartment of the tumor is removed
Ex: entire limb/organ
What are two common radical excision applications?
Amputation or hemipelvectomy
What surgical system does Dr. Cav prefer to follow most?
Fulcher system
What is the Fulcher system?
Circle tumor and measure out 1, 2 and 3 cm to determine feasible margins
What is the difference between a grade I vs grade II Fulcher tumor?
Grade I: 100% clean at 1, 2, and 3 cm
Grade II: 68% clean at 1 cm; 90% clean at 2 cm; 100% clean at 3 cm margins
Which system follows the modified proportional margins technique?
Pratschke system- MCT excision
What is the definition of the Pratschke system?
Widest diameter of the tumor used as the lateral margin for excision
If a tumor is > 4cm in diameter, you will not go past this length out
What percentage are complete margins obtained?
82% of cases complete margins are obtained
What are the margins for acanthomatous ameloblastoma vs malignant oral tumors?
B9: 1 cm
Malignant: 2 cm
Which two tumors constantly change margin sizes?
Thyroid tumors
Anal sac tumors
Which tumors should be inked and how should this be done?
Ink ALL TUMORS
Ink all cut surfaces, NOT SKIN
Prior to breadloafing and fixation in formalin
What is the dye system used to ink tumors and which colors should be used?
Davidson Dye system
Yellow or Black colors
What should be provided on the submission form when submitting a tumor biopsy sample?
Signalment
Pertinent clinical infomration about tumor
Anatomical site of sx
Lesion description
What is the tissue to formalin ration?
1:10
What is the ideal tissue thickness for tumors to be placed in formalin?
0.5-1.0 cm tissue thickness
How far should the breadloaf cuts be made apart?
2 cm apart- incomplete cuts
What is the optimal method for biopsy submission?
Small volume biopsy submission- place sample in screen cassette
“Complete but close” refers to what in margin terminology?
Tumor cells w/in 1 mm of cut edge
“Complete” excision marginal terminology means what?
> 2mm of normal tissue between tumor & inked edges in all directions
“narrow” excision marginal terminology means what?
2-5 mm of normal tissue between tumor and cut edge
What is the percentage of diagnostic agreement between 1st and 2nd opinions?
52%
What is the difference between R0, R1 and R2?
R0- no residual tumor
R1- microscopic residual tumor
R2- macroscopic residual tumor
