L17: Surgical Oncology (Boston) Flashcards Preview

Surgery (Spring 2015) > L17: Surgical Oncology (Boston) > Flashcards

Flashcards in L17: Surgical Oncology (Boston) Deck (23):
1

Three Little Questions***

1) What is it?
2) Where is it? (staging)
3) How bad is it? (prognosis, tx options)

2

How to determine what it is

-FNA
-Tru-cut biopsy
-incisional biopsy (takes very small sample)
-excisional biopsy
-presumptive diagnosis`

3

When and why is incisional biopsy done?

-FNA nondiagnostic or non exfoliating
-easy access to mass (externally or via U/S)
-diagnosis and/or grade will change the definitive surgery done

4

how is incisional biopsy done?***

Needle-Core Biopsy
-tru-cut biopsy
-Jamshidi biopsy
Wedge Biopsy
Punch Biopsy
***Principle: the structure of the tumor remains intact. No seeding of the tumor or disruption of fascial planes around the tumor

5

Tru-cut Biopsy method

-(takes small amt. of core tissue)
-sedation and local anesthesia
-high accuracy rate
-low complication rate
-take multiple samples to improve diagnostic accuracy

6

Incisional biopsy technique

-wedge or punch biopsy
-sedation w/ local anesthesia or general anesthetic
-aseptic technique
-goal = achieve a histological dx w/ minimal disruption of the mass
-don't worry about getting junction of normal and abnormal tissue; this may seed tumor into normal tissue!
-go deep, not wide
-don't aim for center either - may get necrotic material

7

Wide vs. Marginal Excisional Biopsy

Marginal or Wide:
-Marginal: doesn't disrupt fascial planes, but may need to come back for wide definitive excision
-Wide: cuts with curative intent

8

Principles of Excisional Biopsy

-dx will not change the surgical procedure for certain things: ie splenic mass, pulmonary mass, primary bone tumor. The bottom line is they need to be resected!
-high likelihood of incomplete resection
-tissue architecture destroyed
-complete surgical resection more difficult
-recurrent tumors may be more aggressive

9

Principles of Primary reexcision

-wide excision of the scar including a fascial plane deep

10

which more important: histologic description or diagnosis?

description
-grade helps us to predict the biological behavior of the tumor

11

What is STAGE?***

-extent of a cancer in the body
-size of the tumor
-regional LNs contain cancer
-distant spread (mets)
-determined w/ Rads, U/S, CT, MRI

12

What is GRADE?***

microscopic variables:
-degree of differentiation
-mitotic index
-% necrosis
-invasion of lymphatic or blood vessels

13

plan is based on what factors

diagnosis
stage of disease
owner's goals
patient's overall health

14

what are the goals of different surgical doses?***

Intralesional excision: palliative
Marginal excision: palliative/curative potential (esp. if combined with radiation)
Wide excision: curative potential (2-3cm margins with fascial layer underneath)
Radical Excision: curative potential (removes an anatomic segment)

15

Intralesional excision

-residual gross tumor left behind
-"shell out"
-goal is generally palliation
-can consider this approach prior to radiation in certain circumstances
-local control not possible
-recurrence is a certainty
-MACROscopic tumor left behind

16

Marginal excision

-residual MICROscopic tumor cells at sx site
-minimal margins
-combine with radiation for curative intent
-indications:
lipoma; sarcoma of distal extremities ONLY if followed up with radiation; cytoreductive sx for dz that has already metastasized

17

Wide Excision

-lateral and deep surgical margins that will completely remove macroscopic and microscopic tumor burden
-margins 3cm lateral and one fascial plane deep
-often requires MRI or CT for preop planning

18

fascial planes

fascia
muscle
bone
chest wall
*psuedocapsule, SC tissue, and fat are NOT fascial planes*`

19

radical excision

-same goal as wide resection but curative excision requires removal of body part or anatomic segment

20

penrose drains

-must exit ventrally
-need to bandage wound
-risk of contamination of drain tract with tumor cells
-entire drain tract must be resected on reexcision or treated with radiation
-seroma can spread cancer cells

21

closed suction drains

-exit directly adjacent to incision
-no need to bandage
-decrease risk of seroma formation
-useful for skin flaps

22

when to change gloves/instruments

-between biopsies or mass removals
-for flap or graft at donor site
-probably not necessary if anticipate dirty OR clean margins
-radical excision: not necessary

23

Principles for when tumor capsule is inadvertently entered

-inc. likelihood w/o a CT or MRI
-close the site where tumor capsule entered
-lavage the site
-change gloves and instruments
-convert to a wider and deeper excision