Surgical Oncology

What do you look for when physically examining a mass?

Gross appearance, consistency, size, mobility

Palpation of regional lymph nodes

What is staging of a tumor?

Diagnostic process to determine extent of disease progression

What should be done prior to tumor removal?

Identify type of tumor

Why should you determine the tumor type?

Tumor behavior can influence management by telling you

• Degree of invasion

• Metastatic potential

• Biologic activity

T/F you should never remove a mass without attempting a FNA first?

True

What are FNAs good for diagnosing?

Mast cell tumors

Melanoma

Lymphoma

Describe an FNA

A good screening test that is not usually definitive

What is the gold standard for determining tumor type

Histopathology

What are some risks of a biopsy?

Invasiveness of procedure

Hemorrhage

Seeding of tumor cells

Describe biopsies

Not always a straightforward decision, cytology might not give enough information, additional information might not affect case management

What is an incisional biopsy?

Sharp removal of a portion of the tumor

What is a downside of an incisional biopsy?

It requires a second surgical procedure to remove the tumor after diagnosis

Can create a direct communication between tumor tissue and normal surrounding tissue

How do you need to plan an incisional biopsy?

So biopsy track can be easily excised with definitive surgery

What are the techniques for an incisional biopsy?

Tru-cut biopsy

Punch biopsy

Surgical incision biopsy

What is the downside of a tru-cut biopsy?

It only gets a small section

What is a benefit of a tru-cut biopsy?

It can be done with just a local block

When are punch biopsies good?

Dermal masses

How do you do a surgical incision biopsy?

On the border of the mass into the normal tissue

What is the downside of a surgical incision biopsy?

It causes you to increase your margins when you remove it because you make clean tissue dirty

What is an excisional biopsy?

Removal of entire tumor along with surrounding barrier of normal tissue

What is the benefit of an excisional biopsy?

Biopsy and gross tumor was removed in one procedure

What is the downside of an excisional biopsy?

The margins may not be wide enough based on the aggressiveness of the lesion

What are important factors for an excisional biopsy?

Cytology and anatomic location

What should the ideal biopsy do?

Provide enough tissue for pathologist to diagnose

Not jeopardize patient well being

Not hinder surgeon for future surgery

What is the significance of the necrotic core found in some masses?

If that section is biopsied, then it can prevent diagnosis

Why do you need imaging after diagnosing a tumor?

Metastasis screening

What imaging do you want to plan a tumor removal?

Radiograph, US, CT/MRI

What are the types of margins of excision?

Radical

Wide

Marginal

Intralesional

What is the most common mistake of margin of excision?

Too low of a surgical dose

What is the point of a wide and radical margin?

Curative intent

What are surgical margins based on?

Tumor type and anatomic location

Describe a wide and radical margin procedure

En bloc removal of gross tumor and determined margins of grossly normal tissue

Why do you remove normal tissue with a wide and radical margin?

Minimize leaving microscopic disease behind

What is the lateral margin for a wide excision?

A measured distance

What is the deep margin for a wide excision?

One fascial plane

Why do you need to go one fascial plane deep with a wide excision?

Fat muscle, and parenchymal tumors are not good barriers for neoplasm but connective tissue is

What is a radical excision?

Removal of an entire tissue compartment

What type of excision is a limb amputation?

Radical

What type of excision is the removal of an entire mammary chain?

Radical

What is a marginal resection?

Dissection occurs just peripheral to pseudocapsule IN the reactive zone

When is marginal resection successful?

Lipomas

When does marginal resection fail?

Malignant neoplasm

What is a planned marginal resection?

You remove a tumor that would normally spread like a sarcoma, then use radiation as an alternative to amputation

What is an intralesional/debulking excision?

Incomplete resection of a tumor with residual gross disease

When is intralesional/debulking excision acceptable?

If the lesion has came back several times, is healthy otherwise, and it is ulcerated. This is done very rarely

What is palliative surgery?

Surgical intervention that will improve the quality of life but has no impact on survival

Limb amputation for a palliative surgery is what?

Palliative surgery

T/F lymph node size is an accurate detector of metastasis?

False

How should you examine the regional lymph node of a tumor?

FNA

What is the benefit to removing a regional lymph node of a tumor?

It can facilitate staging and potentially be cytoreductive

How do you plan a tumor removal?

Define surgical intent

Excise biopsy or needle tracks en block

What tumor should you remove first, malignant or benign?

Benign

How do you handle a tumor?

Like a contaminated abscess

What should be done prior to closure and between masses of a tumor removal?

Change globes and instruments

T/F you should remove drains?

True

How do you close a tumor removal?

Primary closure if possible

What are the margins for mast cell tumors?

2cm lateral and 1 fascial plane deep

What are the margins for a soft tissue sarcoma?

2-3cm wide and 1 fascial plane deep

What are the margins of an intestinal tumor?

3-8cm of healthy bowel

What are the margins for an injection site sarcoma?

5cm and 2 fascial planes

When doing margin assessment what do you have to do?

Request the pathologist to look at the margin

Prive signalment, history, description of mass, provide a key to marked edges

Paint edges

Mark edges with suture

T/F interpretation of the margin should take into account tumor grade and how surgery went?

True

What are complications for a tumor removal?

Local recurrence

Metastasis

Delayed healing / incisional complications