Surgical oncology Flashcards
What is the most common mistake in oncologic surgery? What is this a consequence of?
- Not being aggressive enough on the first excision
- Consequence of inadequate pre-op assessment
What 7-8 things do you need when describing a mass?
- Appearance (e.g. covered with intact skin, ulcerated)
- Density (e.g. firm or soft
- Location (where on the body AND where in regards to tissue layer or organ occupied)
- Mobility relative to adjacent structures
- Painful
- Shape
- Size
How do you identify neoplasia?
- FNA
2. If FNA is non-diagnostic, incisional biopsy ideally
What if an FNA is negative?
- It can rule neoplasia IN but cannot rule it OUT
- If you don’t see tumor cells on an FNA, that doesn’t mean they are not there
When do you do a biopsy?
- If the FNA is non-diagnostic
What is an excisional vs incisional biopsy?
- Excisional is cut the tumor out
- Incisional is remove a PIECE of the mass and submit for histopathology
Why do you often want to identify the mass via FNA or incisional biopsy before you excise?
- ) Knowing tumor type might influence further diagnostics; choice and order of surgery, radiation, and/or chemo; extent of surgery (e.g. 1 cm margins vs 3 cm margins); client’s interest in continuing based on risks, costs, prognosis)
- ) Surgery is not the best mode of treatment for some tumors and can make some worse (e.g. TVT, cutaneous histiocytoma, lymphoma, nasal adenocarcinoma, inflammatory mammary carcinoma)
- ) The first excision is often the best chance for a cure!
What happens if you excise the mass without knowing what it is?
- You can worsen the prognosis if it remains
- Inadequate surgery can select for more aggressive cells because those are the ones that were already moving out from the tumor and thus have inasive/metastatic potential
- Surgery alters vascularity, immune system, and tissue plans –> remaining cells may grow more easily, making subsequent surgeries more difficult
What can happen if you excise with dirty margins?
- If tumor remains, you may need to do another, even bigger surgery +/or chemo +/or radiation
- It also may be harder to cure at that point
What are four reasons for doing an excisional biopsy without doing an incisional biopsy first?
- Mass is too small for incisional biopsy
- Tumor type was already clearly identified with FNA
- Knowing what the tumor is will not change the treatment protocol
- Incisional biopsy is as difficult or risky as excisional (e.g. spleen or lung)
Incisional biopsy preparation
- Scrub gentle (do whether incisional or excisional; don’t want to exfoliate cells or release vasoactive substances with rough handling
How many samples to take from an incisional biopsy?
- Multiple samples
What areas to avoid with incisional biopsy?
- Avoid inflamed or necrotic areas
Hemostasis and electrocautery for incisional biopsy
- Meticulous hemostasis
- Avoid electrocautery on the biopsy itself as it distorts the histopathology
Why is it important to keep a record of incisional biopsy?
- Surgeon doing the definitive surgery needs to know where you did the biopsy
How should you plan the biopsy tract?
- So that it can be removed with desired margins at the definitive surgery
- You must assume that the biopsy tract will be contaminated with tumor cells
Handling of incisional biopsy sample
- Do not crush it
- Use atraumatic forceps
- If possible, only grasp it in one place for the entire time you are handling it
- Place small samples on a piece of paper or in tissue cassette so they don’t get lost
- Avoid putting small samples on a gauze sponge because they can get caught up in the mesh and are hard to transfer to formalin
- It’s easier to put them on a piece of paper as from a suture packet
What is tumor grading?
- Histopathology is used to ID the tumor type and to grade it, which means to determine the degree of differentiation and anaplasia
What is tumor staging?
- Assesses the size of the tumor and how much it has spread, both locally and into distant sites
What does tumor staging include?
- Includes assessing draining lymph nodes (FNA if accessible, even if LN are normal size)
- Includes imaging to look for local invasion and for distant metastatic disease
What else should you do with tumor staging?
- Look for concurrent disease - you don’t want to do extensive treatment for one tumor only to find that the patient has another untreatable or debilitating condition
- Look for paraneoplastic syndromes
What tumors can have hypercalcemia as a paraneoplastic syndrome?
- Anal sac adenocarcinoma
- Lymphoma
- Multiple myeloma
What tumors can have hypoglycemia as a paraneoplastic syndrome?
- Insulinoma
- Liver tumor
- Sarcoma
What tumors can have hyper or hypotension as a paraneoplastic tumor?
- Pheochromocytoma, MCT
Is age a disease?
- NO
Treatment plan for neoplastic mass
- Determine best mode for given tumor - options include surgery, radiation, chemotherapy, or some combination thereof
- If combination, order of these options can be important as well
- Consult with an oncologist and stay current on literature to provide the best treatment for your patient
What is the definitive surgery, and when do you perform it?
- it is the surgery where you excise the mass
- It is performed when you have all of the information you need about the patient’s disease and EXCISE the mass with a specific surgical dose in mind based on that information
Debulk
- Macrosopic disease remains
- To be effective, need to remove >90% of the tumor mass to improve response to subsequent treatment
Marginal
- Microscopic disease remains
Wide margins
- 1-2 cm for most tumors
- 2-3 cm for MCT
- 3 CM for soft tissue sarcomas
- 5 cm for injection site sarcomas
Appropriate margins for injection site sarcomas?
- 5 cm margins + 2 tissue types deep (surgery dose = wide or radical)
Radical surgery
- Remove the compartment (e.g. amputation; whole mammary chain)
What do you need to communicate about the goal of surgery with client communication?
- Curative vs palliative
- Sole treatment vs multi-modal
What do you need to discuss with the client about the risks and complications of surgery?
- Discuss the risks and potential complications of most surgical procedures
- I forget what they are, but you should review this before the test for sure
What all should be communicated to the client about surgery?
- Goal
- Risks and complications of surgery
- Short and long term expectations in terms of functional limitations post-op
- Short term and long-term expectations in terms of appearance post-op
Mammary tumor margin guidelines
- 1-2 cm
- 1+ tissue planes deep if limited on the deep aspect
Mast cell tumor margin guidelines
- 2-3 cm (1+ tissue plane deep)
Soft tissue sarcoma margin guidelines
- 3 cm (1+ tissue planes deep if limited on the deep aspect)
How should you measure margins for removing a mass?
- measure from the furthest most point of any previous biopsy, surgical procedure, and/or drain site associated with the tumor
Why is it the rule that if you can’t get deep enough margins it’s acceptable to remove at least 1 different tissue type or plane beyond that contacted by the tumor?
- generally thought to be harder for tumor cells to move through tissue of a different type than the tissue they started in
- Different tissue type can be a barrier to the tumor’s spread
- Go through the practice examples with this
How should you mark out margins?
- measure twice and cut once
- Use a ruler and cut out margins
What will happen to the size of the skin edge (INCREASE/DECREASE) and the size of the wound (INCREASE/DECREASE) relative to your initial measurements as you incise?
- The size of the skin edge around the tumor will decrease
- The size of the wound will increase
How are margin recommendations made?
- Based on measurement before any cut is made
How do you maintain margins as you go deeper?
- Stay midway between the edges of the skin to maintain margins
- You’re trying to remove a cylinder of tissue; do not cone down as you go deeper or you will compromise margins
How do you mark margins of excised tissue?
- Use suture tags, dye
- These help the pathologist orient the sample and give you information as to which surface might still have tumor cells remaining
What should you do with the tumor after you excise it, even if you have a previous biopsy?
- Always submit for histopathology
- FNAs and biopsies can be wrong, tumors can change over time, and you need to know if you got clean margins
How is oncologic surgery considered in terms of contamination?
- It’s considered contaminated just like opening the GIT, only this time the potential contaminants are tumor cells
How should you treat oncologic procedures?
- Protect normal tissues from contamination, just like when opening the GIT
- DO not cut into a tumor or shell it out - what looks like a nice capsule isolating the tumor may actually be a compressed layer of tumor cells
- Change instruments/gloves and lavage when done with the tumor part of the surgery
Practice the things on page C42 and C43
Just do it
