L17: Surgical Oncology (Boston) Flashcards Preview

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

Three Little Questions***

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


How to determine what it is

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


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


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


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


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


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


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


Principles of Primary reexcision

-wide excision of the scar including a fascial plane deep


which more important: histologic description or diagnosis?

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


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


What is GRADE?***

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


plan is based on what factors

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


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)


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


Marginal excision

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


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


fascial planes

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


radical excision

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


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


closed suction drains

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


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


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