staging, biopsy and natural history of tumors/media/staging biopsy behavior tumors.pdf · attempts...
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STAGING, BIOPSY AND NATURAL HISTORY OF TUMORS
SCOTT D WEINER MD
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WHAT DO YOU DO WHEN THIS SHOWS UP IN YOUR OFFICE?… besides panicking
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tumor pseudocapsule
Reactive zone
KEY PRINCIPLE!!!
Reactive zone is the edema, neovascularity and inflammation that attempts to ‘wall off’ the tumor
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Reactive zone
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IMPORTANT CONCEPTS
• BENIGN TUMOR • No tumor beyond the pseudocapsule • Limited reactive zone
• MALIGNANT TUMOR • Always malignant cells (satellites) in
pseudocapsule and in reactive zone… therefore, shell-out never appropriate
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STAGING
• Local staging • XRay all bone and soft tissue tumors • MRI test of choice
• Distant staging • CT chest and abdomen for all potential
sarcomas • Bone scan (whole body) for bone sarcomas • ?PET scans
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BIOPSY
• Complete staging prior to biopsy • To avoid necrotic regions at biopsy • Defines reactive zone (biopsy site distorts it) • May suggest a sarcoma and possible referral • The entire biopsy tract needs excised • Bad biopsies DO compromise outcomes
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PERONEAL NERVE CONTAMINATED
BIOPSY THROUGH THE FASCIA
JOINT CONTAMINATION
IMPOSSIBLE TO EXCISE
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Types of biopsies
• Fine needle aspiration (FNA) • Not adequate for most soft tissue
masses (best for metastatic, myeloma, lymphoma)
• Yields few disconnected cells • Needs experienced pathologist • Still creates a hematoma • Don’t trust a negative FNA if suspicion
high
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Types of biopsies
• Core biopsy (Tru-Cut) • Best for large easily palpable masses away
from major neurovascular structures • Yields cells plus surrounding stroma (sarcomas
are diagnosed by patterns, not just cells) • Hematomas still occur, sometimes significant
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Tru-Cut technique
• Small incision (marks site)
• Needle to edge of pseudocapsule
• DON’T past point (contaminates deeper structures)
• Multiple passes in different directions but same skin incision
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tumor
NV bundle
biopsy
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Types of biopsies
• Excisional (shell-out) • ONLY for small
superficial lesions and lesions of the fingers and toes
• DO NOT violate deep fascia (watch sutures)
• Same well-planned incisions
Deep fascia
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Finger salvage rarely indicated and most lesions are benign
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OPEN INCISIONAL
• Gold standard still • Tourniquet without exsanguination • Culture all biopsies and biopsy all
infections… antibiotics after biopsy • Consult with pathologist prior to biopsy
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OPEN INCISIONAL
• Longitudinal biopsy along planned definitive resection
• Through expendable muscle
• Away from major NV structures
• Avoid dead spaces
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Biopsy tract
DO YOU KNOW WHERE THE SCIATIC NERVE IS?
Avoid it !!! IF CONTAMINATED, IT NEEDS TO GO
AVOID MAJOR NERVES AND ARTERIES
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OPEN INCISIONAL
• Biopsy the periphery and pseudocapsule
• Always get a frozen section (adequate sample, special study needs)
• Avoid crushing • Hemostasis +/- drain in line with
incision • DO NOT SHELL OUT • Subcuticular closure
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BASIC TREATMENT PRINCIPLES OF TUMORS
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STAGING
• Benign lesions (based on radiographic, clinical features) 1… latent lesion 2… active lesion 3… aggressive lesion
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STAGING
• Malignant lesions (based on histology) I… low grade sarcoma II… high grade sarcoma III… metastatic A… intra-compartmental B… extra-compartmental
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COMPARTMENTS
• Based on the fact that tumors spread along
paths of least resistance • Fascial or periosteal boundaries usually
prevent tumor spread except for some aggressive sarcomas
• Once a sarcoma is into a compartment it can spread freely
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SURGICAL MARGINS
TUMOR
INTRALESIONAL
Cuts into tumor, debulking
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SURGICAL MARGINS
TUMOR
MARGINAL
removes pseudocapsule and lesion but leaves reactive zone
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SURGICAL MARGINS
TUMOR
WIDE RESECTION
Tumor, pseudocapsule and reactive zone removed
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SURGICAL MARGINS
TUMOR
RADICAL RESECTION
removing the entire compartment
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basic principles
• all tumors spread along the path of least resistance • benign lesions are entirely contained within the
pseudocapsule • HISTOLOGIC GRADE of sarcoma most important,
not type!! • ALL sarcomas have SATELLITES (cells in reactive
zone and pseudocapsule) • HIGH-GRADE sarcomas have SKIP lesions (intra-
compartment mets) in addition to satellites • ALL sarcomas can metastasize (lungs, occasionally
lymph nodes)
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BENIGN LESIONS
• MARGINAL EXCISION
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BENIGN AGGRESSIVE TUMORS
GIANT CELL TUMOR Extended intra-lesional curettage (essentially a wide margin)
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LOW GRADE SARCOMAS
Low grade sarcoma
* ** **
MALIGNANT CELLS IN PSEUDOCAPSULE AND REACTIVE ZONE SATELLITES
WIDE MARGIN
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LOW GRADE SARCOMAS
Low grade sarcoma
* ** **
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Remember that the fascia is a excellent qualitative
margin
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HIGH GRADE SARCOMAS
high grade sarcoma
* ** **
MALIGNANT CELLS IN PSEUDOCAPSULE AND REACTIVE ZONE
* * *
BUT ALSO OUTSIDE !!
SKIPS
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HIGH GRADE SARCOMAS
Low grade sarcoma
* ** **
* *
*
WIDE MARGIN INADEQUATE ALONE
MISSES THE SKIPS!!
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RADICAL MARGIN BEST BUT WITH SIGNIFICANT FUNCTIONAL LOSS
HIGH GRADE SARCOMAS
Low grade sarcoma
* ** **
RADICAL RESECTION NEEDED
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HIGH GRADE SARCOMAS
Low grade sarcoma
* ** **
* *
*
WIDE MARGIN MAY BE ADEQUATE WITH ADJUVANT THERAPY
RADIATION for soft tissue sarcomas
CHEMO for bone sarcomas
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RADIATION THERAPY • PRE-OP (50 Gy)
• Less area needs to be radiated • Higher wound complications • I prefer for lesions with expected close margins
• POST-OP (65 Gy) • Greater radiated field to include hematoma • fewer acute wound complications, higher late • I prefer for ‘easy’ wide resections with low
morbidity
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High grade sarcoma… wide resection and radiation therapy
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