Surgical Oncology Flashcards
When is incisional biopsy done
prior to definitive treatment
Pros/cons of incisional biopsy
Pros: better planning, best chance for Sx cure, establish informed consent, appropriate implementation of adjuvant and neoadjuvant tx
Cons: two procedures = more invasive, $$$, progression while waiting for Sx. Increased risk of local recurrence (unless Bx tract removed)
Considerations for incisional Bx
avoid ulcerated/inflammed tissue
delicate tissue handling
plan closure - don’t compromise second Sx
large and multiple samples
orient incision parallel to tension lines
TRU CUT biopsy
incisional
14, 16 or 18G
any accessible mass, maintains structural integrity of tissue
sedation or local anesthetic (tumor tissue has poor innervation)
obtain multiple samples
Punch biopsy
incisional
>6mm to procure dx sample
DO NOT USE FOR HYPODERMAL MASSES - risk undetected hemorrhage
can punch out entire mass if small
Why can’t you use a punch biopsy on a hypodermal mass
Risk undetected hemorrhage (tissue shifts post biopsy)
Wedge biopsy
ulcerated or necrotic tumors or deeply located masses
can increase field of contamination depending on bx location
entire bx tract must be removed at later date
use gelpi retractors to maintain tissue retraction for deeper lying tumors
3 types of incisional biopsy methods
TRU CUT
Wedge
Punch
What is an excisional biopsy?
excise tumor then biopsy
When is an excisional bx indicated?
when Tx wouldn’t be altered by tumor type or grade
if procedure to get mass is invasive or carries high risk (splenectomy, bleeding)
if location permissive of wide margins w/o compromising potential for future re-excision if needed
if benign
3 important concepts regarding excisional bx technique
1 - prevent tumor seeding
2 - eliminate all dead space
3 - do not drain
What is a tumor pseudocapsule?
a reactive zone which may contain microscopic extensions of satellite tumor populations
What is Enneking classification?
classification of surgical dosing - looks at surgical margins of tumors
What is the only indication for a intralesional excision (Enneking classification)?
debulking a lipoma
Marginal excision
can breach pseudo capsule - increases potential of leaving cells behind
tumors on extremities, near important structures (eyes), in perianal region
Wide excision
incise completely around where suspected pseudo capsule is living
Radical excision
removal of entire body compartment, limb or organ (spleen!)
amputation and hemipelvectomy are common radical excision applications
T/F: most wide margin trumps all else
false, most narrow margin trumps all else
a patient comes in and you suspect it has a splenic tumor. Which type of excision would you perform?
Radical - remove the spleen
2 methods of measuring margins
Fulcher and Pratschke-Modified proportional margins
Fulcher method of measuring/choosing margins for MCT
circle tumor then measure out 1, 2, and 3cm
MCT general rule: 3cm lateral and 2 fascial planes deep
margins grade dependent
GR I - 100% clean at 1, 2, 3cm
GR II - 68% at 1cm, 90% at 2cm, 100% at 3cm
Pratschke-Modified Proportional Margins
widest diameter of tumor used as lateral margin from incision
ex: if tumor 1.5cm in diameter, margin is 1.5cm
if tumor diameter >4cm, fixed margin of 4cm used
1 facial plane deep
complete margins in 82% cases
Inking surgical margins
all tumors - ink all cut surfaces but not skin
once ink dries, put in formalin
Davidson dye system - use yellow or black
T/F: you should completely bread load specimens
false - incomplete breadloafing
complete transection or too many cuts - can lose tissue orientation
optimal method to submit a small volume biopsy?
place sample in a screen casette
What is a complete margin
no tumor cells at edge of incision
T/F it is proven that narrow margins are incomplete margins
Not proven but in practice associated w. recommendations for more tx if narrow margins
% of cases that there is diagnostic agreement between 1st and 2nd opinion?
52%
% of major disagreements between 1st and 2nd opinion that affect tx or px?
37%
