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Flashcards in Principles of Surgical Oncology Deck (49):
1

Surgery for biopsy - Definition

Retrieval of cells or tissue from the tumour to allow -
Diagnosis & prognosis (grading and staging)
Indication of appropriate therapy
The owner to make a decision about treatment

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Biopsy of: T, N or M

• T: 1y tumour
• N: Lymph node
• M: Metastases

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when to biopsy

If the treatment plan would be changed by the outcome - Type + extent of treatment (Sx vs chemotx vs radiotx), (conservative vs aggressive)
If the owner’s decision to treat would be changed - Tumour type & grade, Clinical stage & Prognosis
If lesion is in a “difficult” area - Head & neck, Distal limb

4

when not to biopsy

treatment plan would not be changed -Mammary masses, single large lung masses
No change in owner’s willingness to treat - Chest wall/limb sarcoma resection
biopsy is difficult - CNS mass lesions, Thyroid tumours, Small intestine tumours

5

key steps in tumour biopsy

biopsy at correct time i.e. early in the course of the disease
use correct technique
submit sample to experienced
read report carefully + speak to the pathologist

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Reason for biopsy - Subcutaneous mass on the flank

Lipoma vs Mast cell tumour vs Soft tissue sarcoma
Differ in - Surgical margin + Prognosis

7

Reason for biopsy - Large cranial mediastinal mass

thymoma or lymphoma?
Differ in - Necessity for surgery + Prognosis

8

Reason for biopsy - Mandibular mass

Acanthomatous epulis vs fibrosarcoma vs melanoma
Differ in - Surgical margins + Prognosis (cure vs palliation)

9

information from biopsy

Definitive diagnosis of neoplasia
Aggressiveness of neoplasia (Benign/malignant)
Cytologic type of neoplasia (Round cell vs epithelial vs mesenchymal)
Histologic features (histological type +Grade of tumour)
Evaluation of metastases
assessment of margins

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considerations for biopsy

Pre-biopsy considerations
Regional considerations
Biopsy technique
Which part of lesion to biopsy
How to submit samples
How to read the histology report

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Biopsy Techniques

needle
incisional
excisional
core
punch

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prophylactic surgery

Reduces the incidence of a particular tumour
Reduces the recurrence rate after treatment
Tissue removed may be - normal tissue: gonads or Abnormal tissue: pre-malignant change
Indications - Increased risk of tumour development, Confirmed dx of pre-malignant change or neoplasia, Surgical excision not associated with high morbidity

13

definitive excision

The use of surgery as the sole treatment, without
adjunctive therapy, to achieve an outright cure
The removal of all the tumour at one surgery
Indications - Localised disease, Regional metastases (occasionally)
N.B. Surgery may not remove 100% of tumour cells The immune response may remove the remainder

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advantages of surgery

Immediate cure
Not carcinogenic
No local toxic effects
Not immunosuppressive
Better for large masses

15

disadvantages of surgery

Local cure only
Change in cosmesis
Change in function

16

principles of surgical excision

establish a diagnosis by biopsy + plan surgery
perform surgery early in course of disease
1st surgery high highest success rate
adequate margins needed in 3 dimensions
margins of excision shouldn't be compromised by concerns with closure

17

planning surgery

Histological diagnosis
Extent of local disease
Presence of local or distant metastasis
nutritional status of the patient

18

correct surgery 1st time

Untreated tumours have normal regional anatomy which facilitates removal
Recurrent tumours may have seeded into previously non-involved tissue planes making it difficult to predict tumour extension, hence a wider resection is required
most active & invasive parts of the tumour are at the periphery; incomplete excision leaves the aggressive cells behind
less normal tissue after previous surgery making closure more difficult

19

post-operative changes

Cosmetic appearance vs function
cosmesis is our concern, not the patient’s
explain with pictures & contact with other clients

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common reasons for failure of definitive tumour excision

fail to plan surgery, usually due to lack of biopsy
fail to stick to plan, usually due to closure concerns

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margins of excision

“Normal” tissue around tumour infiltrated by tumour cells
Finger-like projections
Satellite metastases
“Skip” metastases
Removal of the tumour & a margin of normal tissue
The nature of the margin depends on the tumour
Margin given as - Distance e.g. 1-3 cm, Natural barrier to tumour growth e.g. fascia (esp sarcomas)

22

pseudocapsule

A zone of compressed tissue around the tumour This zone contains viable tumour cells
Do not enter the pseudocapsule - Do NOT “shell-out”

23

local excision

Tumour removed through natural capsule or immediate boundaries
Indications: Benign tumours & no local invasion, lipoma, histiocytoma, sebaceous adenoma
Preservation of adjacent tissue
Thyroid adenoma, CNS
Contraindications - Local invasion, Malignancy

24

wide local excision

Tumour removed with substantial margin of normal tissue
Indications: Benign tumours/local invasion, Malignancy/limited local invasion
Contraindications - More invasive malignancies, Higher grade tumours

25

radical excision

Margins extend into fascial planes undisturbed by tumour growth
Indications - Malignancy & local invasion

26

4 types of radical excision

Radical local excision
compartmental excision
Muscle group excision
Amputation

27

radical local excision

Tumour removed with extensive margins of tissue
including 1 or 2 fascial planes beyond gross tumour
Invasive sarcomas of the abdominal or chest wall - Chest or abdominal wall resection
Invasive carcinoma of the nasal planum - Nasal planum resection & premaxillectomy
Invasive tumours involving eyelids - Excision of eyelids & orbital contents
Invasive orbital/periorbital tumours - Orbitectomy

28

compartmental excision

Tumour removed in an intact anatomic compartment
Indications - Invasive tumours involving limbs, Invasive tumours on the trunk

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muscle group excision

Tumour removed along with the muscle it involves
Indications - Small tumours involving muscle bellies, No breach of fascial plane, or breach which is
excised

30

amputation

Tumour removed with the entire limb
Indications - Large tumours - other method not possible, If radical excision impairs function - bone/joint excision, Management of recurrences - disturbed fascial planes

31

inadequate excision

leads to: Local recurrence, Persistence of tumour & increased chance of metastasis
Usually due to - Inadequate surgical plan (failure to biopsy), Failure to follow surgical plan (concerns re closure)
Options - Re-operate – wider margins, Adjunctive therapy, Radiotherapy, Chemotherapy

32

preparation for histology

Anatomically relevant - Lay out as in vivo +/- sutures
Indicate margins of interest -Closest to tumour
Methods of marking margins - Suture tag, Paint with ink, Draw a picture to orientate
Provide a history - Relevant & detailed

33

evaluation of the tissue

Not optional item
If worth removing - worth histopathology
not sole way of identifying the tumour - i.e. care with excisional biopsy – incomplete excision

34

excisional histology info

Histological type of tumour - Confirms pre-op knowledge of tissue type
Histological grade of tumour - Mitotic index, differentiation, necrosis
Regional lymph node status - access
Staging of disease
Margins – adequacy of excision, Predicts local recurrence
Vascular or lymphatic invasion - Predicts distant metastasis

35

evaluations of margins

False negative - Tumour present at margins - but not the one examined
False positive - Tumour present - but edge examined is not a margin
Specimen incorrectly oriented

36

cytoreductive surgery - define

The planned incomplete removal of the tumour
To improve the efficacy of other modalities

37

cytoreductive surgery - indications

Essential structures (CNS tumours)
Surgical management of recurrences
Unknown tumour borders
Local recurrence likely (SA distal limb)
Highly malignant tumours
Vaccine-associated sarcomas

38

Adjunctive therapies - pre-op therapy

To reduce tumour bulk prior to surgery e.g. sarcoma

39

Adjunctive therapies - intra-op therapy

To gain access to tumours e.g. bladder tumour

40

Adjunctive therapies - post-op therapy

treat small no. of rapidly proliferating, well-oxygenated cells e.g. mast cell tumour

41

Adjunct Treatments for Cancer

chemotherapy
radiation therapy
immunotherapy
hyperthermia
photodynamic therapy

42

chemotherapy

treat invasive or metastatic tumours not completely removed by surgery
used before or after surgery
debulk at least 90% of the tumour
potential complications-delayed wound healing, vomiting, diarrhoea, nephrotox., bone marrow
suppression

43

radiation therapy

fractions of radiation directed at the tumour
used before, during or after surgery
shrink the tumour before or destroy any remaining cells after surgery
potential for early or late moist desquamation or ulceration of tissues

44

immunotherapy

elements of the immune system used against
tumours
interleukins, cytokines, interferons, CSF, monoclonal antibodies
rapidly developing area of research to find very specific effect on tumours

45

hyperthermia

hyperthermia used to destroy tumour cells that are sensitive to temperature changes
used locally or systemically
often combined with chemo. or radiation therapy
currently not a very practical method

46

photodynamic surgery

the use of various wavelengths of light to destroy tumour cells
sensitising agents given to the patient are taken up by tumours cells
the tumour is exposed to light causing a reaction with the sensitising agent
the result is destruction of tumour cells

47

Palliative surgery - Definition

Surgery performed to improve quality of life, for pain relief, improved function of the affected part, or to eliminate life-threatening complications
Consider balance between potential gain vs morbidity

48

palliative surgery - indications

Tumour with metastasis
Complete excision impossible

49

palliative surgery - examples

Limb amputation for osteosarcoma
Splenectomy for haemangiosarcoma
Placement of a cystostomy catheter for TCC
Removal of ulcerated mammary tumours
Mandibulectomy for oral melanoma
Pericardectomy