Surgical Oncology

Question 1

When is incisional biopsy done

Answer 1

prior to definitive treatment

Question 2

Pros/cons of incisional biopsy

Answer 2

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)

Question 3

Considerations for incisional Bx

Answer 3

avoid ulcerated/inflammed tissue
delicate tissue handling
plan closure - don’t compromise second Sx
large and multiple samples
orient incision parallel to tension lines

Question 4

TRU CUT biopsy

Answer 4

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

Question 5

Punch biopsy

Answer 5

incisional
>6mm to procure dx sample
DO NOT USE FOR HYPODERMAL MASSES - risk undetected hemorrhage
can punch out entire mass if small

Question 6

Why can’t you use a punch biopsy on a hypodermal mass

Answer 6

Risk undetected hemorrhage (tissue shifts post biopsy)

Question 7

Wedge biopsy

Answer 7

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

Question 8

3 types of incisional biopsy methods

Answer 8

TRU CUT
Wedge
Punch

Question 9

What is an excisional biopsy?

Answer 9

excise tumor then biopsy

Question 10

When is an excisional bx indicated?

Answer 10

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

Question 11

3 important concepts regarding excisional bx technique

Answer 11

1 - prevent tumor seeding
2 - eliminate all dead space
3 - do not drain

Question 12

What is a tumor pseudocapsule?

Answer 12

a reactive zone which may contain microscopic extensions of satellite tumor populations

Question 13

What is Enneking classification?

Answer 13

classification of surgical dosing - looks at surgical margins of tumors

Question 14

What is the only indication for a intralesional excision (Enneking classification)?

Answer 14

debulking a lipoma

Question 15

Marginal excision

Answer 15

can breach pseudo capsule - increases potential of leaving cells behind
tumors on extremities, near important structures (eyes), in perianal region

Question 16

Wide excision

Answer 16

incise completely around where suspected pseudo capsule is living

Question 17

Radical excision

Answer 17

removal of entire body compartment, limb or organ (spleen!)

amputation and hemipelvectomy are common radical excision applications

Question 18

T/F: most wide margin trumps all else

Answer 18

false, most narrow margin trumps all else

Question 19

a patient comes in and you suspect it has a splenic tumor. Which type of excision would you perform?

Answer 19

Radical - remove the spleen

Question 20

2 methods of measuring margins

Answer 20

Fulcher and Pratschke-Modified proportional margins

Question 21

Fulcher method of measuring/choosing margins for MCT

Answer 21

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

Question 22

Pratschke-Modified Proportional Margins

Answer 22

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

Question 23

Inking surgical margins

Answer 23

all tumors - ink all cut surfaces but not skin
once ink dries, put in formalin
Davidson dye system - use yellow or black

Question 24

T/F: you should completely bread load specimens

Answer 24

false - incomplete breadloafing

complete transection or too many cuts - can lose tissue orientation

Question 25

optimal method to submit a small volume biopsy?

Answer 25

place sample in a screen casette

Question 26

What is a complete margin

Answer 26

no tumor cells at edge of incision

Question 27

T/F it is proven that narrow margins are incomplete margins

Answer 27

Not proven but in practice associated w. recommendations for more tx if narrow margins

Question 28

% of cases that there is diagnostic agreement between 1st and 2nd opinion?

Answer 28

52%

Question 29

% of major disagreements between 1st and 2nd opinion that affect tx or px?

Answer 29

37%