Biopsy and Mass removal

Surgical oncology

surgery in the management of cancer

Surgery in the management of cancer

diagnosis

cure

palliation of clinical signs

debulking prior to adjunctive therapy

ancillary procedures

- placement of a vascular access port

- spay/neuter

Work up and diagnosis of cancer

history

pe

clinical pathology

diagnostic imaging

tissue sampling

surgery

history pertaining to the mass

location, number

duration

size

Map location and size of masses (body map)

clinical pathology based on the work up and diagnosis of cancer

cbc/chem

urinalysis

cytology

ACTH stim test or Dexamethasone suppression test

ionized calcium

parathyroid hormone panel

diagnostic imaging for cancer

radiographs

staging looking for metastasis (3 view thoracic, 2 view abdominal)

ultrasound

computed tomography

magnetic resonance imaging

nuclear scintigraphy

2 ways to diagnose the type of cancer

biopsy

surgical removal with histologic examination

treatment will differ depending on tumor

tumor type, tumor behavior (benign, malignant, aggressive, non-aggressive)

plans for surgical resection

margins and prognosis

tissue sampling techniques

impression smears FNA

minimally invasive biopsy techniques

needle core biopsy (tru-cut biopsy, bone biopsy)

punch biopsy

image guided biopsy (ultrasound or CT)

surgical biopsy techniques

incisional

excisional

biopsy via minimally invasive surgery techniques (laparoscopic, thoracoscopic arthroscopic)

direct sampling of superficial ulcerated lesions or other exfoliated cells (TCC in urine)

impression smear

how to perform an impresison smear

press glass slide against open lesion or cut edge of excised lesion

characteristics of impression smears

cheap

noninvasive

no sedation needed

immediate result (preliminary reading)

send to pathologist

technique of impression smears - Open lesion

blot surface with paper towel

press slide firmly against lesion

pull straight up when removing

impression smear technique - excised lesion

gently touch surface to glass slide

make several smears on each slide

do not squash, twist, rub tissues on slide

characteristics of FNA

easy minimally invasive cheap no sedation needed

LOW DIAGNOSTIC YIELD

syringes and needle needed for FNA

20-22 gauge needle

too big =painful

too small = no cells, lyse cells

3-5 cc syringe

too big = not enough suction

too small = too much suction gets blood contamination

what are the two techniques for FNA

woodpecker and suction

describe how to perform FNA woodpecker technique

needle placed in mass

quickly stab repeatedly

move needle tip direction

do NOT remove needle from skin until finished

remove syring and pull plunger back

reattach needle

push plunger down rapidly to squirt cells onto a labeled slide

explain the FNA suction technique

needle placed in mass

quickly pull plunger back 1-2 mls

repeat in same spot 3-4 times

if you get blood, STOP

do NOT remove needle from skin until finished

remove syringe and pull plunger back

reattach needle

push plunger down rapidly to squirt cells onto a labeled side

FNA technique

Components of biopsy planning

selection of biopsy site

tract can be excised

center of lesion (internal organs, diffuse lesions)

edge of lesion (cutaneous mass, distinct mass on internal organs, include adjacent normal tissue)

do not open new tissue planes

biopsy planning

Indications for needle core biopsy

no diagnosis with FNA or impression smear

need more tissue for characterization

uses for needle core biopsy

palpable masses (skin, muscle bone)

organs visible by ultrasound or CT (near body wall, liver or kidney)

needle core biopsy tool for soft tissues

tru-cut biopsy needle (manual and automatic)

needle core biopsy tools for bone

jamshidi needle

michele trephine

Tru-cut biopsy needle

Jamshidi needle

Michele trephine

Tru-cut needle biopsy methods

percutaneous

intraop

ultrasound guided

palpation

blind

trucut needle biopsy requires

sedation or anesthesia

surgical prep of site for tru-cut needle biopsy

clip

scrub

sterile gloves

Tru-cut biopsy technique

larger needle

cuts a core of tissue from mass

tissue for histology

Tru-cut biopsy technique

Bone biopsy indications

diagnosis of proliferative or lytic bony lesions

eval of bone marrow

methods of bone biopsy

jamshidi bone biopsy needle (smaller)

Michele trephine (larger core and higher risk of pathologic fracture)

gen anesthesia

surgical prep

Bone biopsy using Jamshidi needle

Locations for bone marrow biopsy

proximal humerus

ilial wing

proximal femur

proximal tibia (young dogs only)

Indications for punch biopsy

cutaneous masses

focal organ masses (liver, pancreas, spleen)

instrumentation for punch biopsy

baker skin biopsy punch

Baker skin biopsy punch

method for punch biopsy

sample from edge of lesion

include normal tissue

do not penetrate deeper tissue

sedation or anesthesia

surgical prep

punch biopsy technique

punch biopsy technique

insert perpendicular to surface (rotate to cut)

use scissors to release base (gently pick up with thumb forceps)

Punch biopsy technique

Incisional and excisional biopsy

Indications for incisional biopsy

large, superficial lesions (ulcerated lesions)

lesion is located in area where achieving margins and closure may be difficult

when less invasive techniques fail to yield a diagnosis

type/aggressiveness of tumor would change treatment plan

Excisional biopsy tx choice

treatment choice unchanged by tumor type (benign tumors/lesions)

lesion is in place amenable to wider excision if needed

both diagnosis and treatment

Excisional biopsy

keys to obtaining diagnostic biopsies

adequate sample size

number of samples

biopsy junction of normal and abnormal tissues where possible

handle tissues gently

give pathologist detailed info

surgical tx of cancer - best chance to cure cancer is with complete surgical _____ __ _ ________

excision the first time

what cures more patients than any other type of treatment

complete excision

the amount of normal tissue removed with the tumor

margins

margin for cutaneous carcinomas

1 cm

margins for mast cell tumors

2-3cm - 1 fascial plane deep

Margins for cutaeneous sarcomas

3-5 cm (1 fascial plane deep soft tissue, 2 fascial planes deep vaccine-associated)

what tumors need no margins

benign tumors with low risk of recurrence

- lipoma

- masses in body cavities

classifications of margins

intracapsular

marginal

wide excision

radical excision

Intracapsular margins

removal from within capsule or pseudocapsule

debulking

marginal margins

removed at margin of tumor

capsule intact

little or no normal surrounding tissue

wide excision margins

removed with margin of normal tissue surrounding tumor

fascial planes deep to tumor

radical excision margins

removal of entire affected tissue compartment

Margins

Margins

contamination of surgical site

if capsule entered

lavage surgical field

change gloves

new instruments

increases risk of recurrence

sample preparation

handle tissue gently

do NOT crush

handling artifacts adversely affects tissue quality and diagnosis

mark surgical margins with what

suture

ink

- india ink

- alcian blue

colored inks

painting areas

painting margins

apply to cut surface with cotton tip applicator

- do not double dip

allow ink to dry (10-20 mins)

painting margins

Painting margins - appearance on histology

What is the common fixative used for tissue fixation?

10% formalin

What is the recommended ratio of tissue to buffered formalin for fixation?

1 part tissue to 10 parts buffered formalin

How deep does formalin penetrate tissue?

1 cm

What is the recommended method for fixing bread loaf tissues thicker than 1 cm?

Use bread loaf techniques to allow fixation of all tissues

What should be done with each lesion during tissue fixation?

Use a separate container for each lesion

What is used for very small tissue samples during fixation?

A tissue cassette

labeling slides

pencil or slide marking pen

no pen or sharpie etc

comes off during staining

labeling histopathology hars

write on label +/- lid

use pre-printed patient label

labeling - samples

date

patient name and id number

location of lesion

cutaenous mass - right forelimb

liver biopsy left medial lobe

jejunum

submission forms

patient info (name/number)

signalment

complete history

clincial findings with gross appearance

tentative diagnosis

request margin check if needed

junk in = junk out

debulking surgery

removes majority of mass - cytoreduction

intended to follow up with other therapy

- radiation

- chemo

- photodynamic therapy

palliative surgery

meant to improve quality of life

not meant for cure or to extend life

surgery for metastatic disease used in people for solitary metastasis

lung brain liver

may prolong survival in dogs - surgery for metastatic disease

removal of metastatic sublumbar lymph nodes in dogs with anal sac adenocarcinoma

regional lymph nodes should always be assessed for

tumor staging (how much of body is affected)

cytologic evaluation by FNA is recommended even if

lymph nodes are normal on palpation

_______ will reduce the incidence of mammary tumors

spaying

_____ can treat/prevent perianal adenomas, testicular tumors (esp. retained testicles) and possible prostatic adenocarcinoma

castration

excision of precancerous lesions may prevent progresison of disease

squamous cell carcinoma

adenomatous polyps

keys to obtaining diagnostic biopsies

sample size

number of samples

biopsy junction of normal/abnormal tissue

handle biopsy gently to avoid artifacts

give pathologists details

wide surgical excision of a mass