Principles of Surgical Oncology

Cassie N. Lux, DVM, DACVS-SA

CVMTY Congreso Veterinario de Monterrey, 2016

Thorough patient assessment is necessary prior to any surgical intervention for a

neoplastic lesion. A good physical exam will provide information on other co-morbidities which
may make anesthesia risky or provide suspicion for potential metastatic disease. Most staging
protocols involve thoracic radiographs, abdominal ultrasound, and assessment of regional and
distant lymph nodes. Oftentimes, large or invasive tumors will require advance imaging
diagnostics such as computed tomography (CT) or magnetic resonance imaging (MRI).
Accumulating as much information as possible about a mass is important prior to surgical
intervention. The least invasive method for obtaining a sample of a mass is via fine needle
aspirate (FNA). The cytology from this technique may provide a diagnosis or suspicion of a
diagnosis. Areas of extreme inflammation can have cellular changes which resemble neoplastic
transformation, and it is important not to over-interpret these results. In this situation, a biopsy is
generally warranted to achieve a diagnosis. Neoplasia such as mast cell tumors (MCT),
lymphoma, and melanoma are often easily diagnosed on cytology from a FNA.
Important things to consider when performing a biopsy include what the information will
provide to case management, what risks are involved in performing the biopsy, and how the
biopsy will change tumor behavior. Biopsy can guide case management, dose of surgery, and
provide important information on prognostication. Risks of biopsy include rupture of the mass
(cavitated splenic or liver masses) and spread of the neoplasia to local tissues and body wall
(intra-cavitary masses). Needle biopsy is most commonly performed for tumors within body
cavities. These can be performed under heavy sedation percutaneously, or with general
anesthesia via an open surgery (thoracotomy or laparotomy) or minimally invasive approach
(laparoscopy). The main disadvantages of this procedure are that often the approach is poor
control for hemorrhage, small samples, and body wall metastasis. This is most commonly
performed via use of a Tru-cut biopsy needle. Incisional biopsy is performed by sharp incision
into and removal of a portion of the tumor. The majority of the tumor should remain intact. This
can often be performed under heavy sedation, but may introduce neoplastic cells to normal
tissue, a second surgery is necessary for treatment of the tumor, and the biopsy may increase the
surgical margin. Location of the incisional biopsy should be at the periphery of the tumor to
avoid any central necrosis, but still within its confines so as not to increase the lateral margin of
the tumor. Excisional biopsy is performed by surgical excision of all gross disease with a small
barrier of normal tissue (removal of the pseudocapsule). The main benefit of this procedure is
that it could be curative for benign masses. The disadvantages with this surgery are that it often
requires general anesthesia (especially for larger masses), and with malignant neoplasia it rarely
results in removal of all disease. Malignant neoplasia often has deep extension into the tissues
and satellite tumor cells outside of the gross disease and incomplete removal often results in
rapid regrowth of tumor and occasionally more aggressive behavior. For neoplastic lesions of
bone, a specialized bone biopsy instrument is often needed. The most common are the Jamshidi
biopsy needle and the Michele trephine.
Surgical intent refers the outcome the Oncology team (medical, radiation, and surgical
0ncologist) hopes to achieve with surgery (ie. is the goal a tumor-free margin). The Oncology
team makes this decision based on staging information, advanced imaging, tumor behavior, and
the likelihood of achieving a tumor-free margin. Instances where the goal of surgery is not a
tumor-free margin may be due to the fact that the surgical procedure may change quality of life,
be disfiguring, have no advantage towards treatment, or be life-threatening/not compatible with
life. Curative intent surgery (achieve a tumor-free margin and cure the tumor), palliative intent
surgery (improve quality of life), and cytoreductive surgery (debulking) are the main categories
of surgical intent.
Surgical dose refers to the amount or level of surgical resection which is dependent on
the intent of surgery, the local invasiveness and behavior of the tumor, how far it extends into
local tissues, and what local tissues are invaded. Tumor is surrounded by a pseudocapsule which
contains fibrous tissue in reaction to growing mass, for more benign masses this pseudocapsule
may keep the neoplastic cells contained, but for malignant masses the pseudocapsule does not
prevent spread of neoplastic cells. Wide and radical excision surgeries are generally performed
with a curative intent. Marginal excision is a planned excisional biopsy; it involves removal of
all gross disease and the pseudocapsule, but will result in a dirty margin with malignant
neoplasia. Debulking is a type of cytoreductive surgery and leaves behind residual gross disease.
Surgical excision of a lymph node (lymphadenectomy) is often performed when a FNA
reveals suspicion of metastatic disease. Palpation of the size and texture of the lymph node is not
always predictive of metastatic disease, and often a FNA or excision is required for confirmation.
In some types of neoplasia, removal of a metastatic node is considered a reduction in gross
disease and recommended for therapy, and often they are removed with limb amputations.
Surgical Concepts: When performing any oncologic surgery it is important to keep a
few important tips in mind: excise all previous biopsy tracts, ligate vasculature early to minimize
distant metastasis (venous first), minimize direct handling of the tumor, and change all gloves
and instruments between removal and closure. As tumors grown, they develop
neovascularization which leads to many large blood vessels being present in areas that
previously didn’t contain them; hemostasis is very important. Suture material should be
monofilament because multifilament can trap neoplastic cells, and long lasting but absorbable.
Polydioxanone (PDS) and polyglyconate (Maxon) are appropriate suture choices. Placement of
drains should be avoided unless necessary as this disrupts tissue planes, spreads neoplastic
disease, and increases the area which needs to be targeted if radiation therapy is necessary. If
radiation therapy is expected to be performed after surgery, the area of excision can be marked
with hemoclips as radio-opaque tags for the previous surgery site. Closure of an excision site can
be challenging, but primary closure is always recommended over reconstructive techniques.
When using skin flaps, the entire donor site is considered contaminated with neoplastic cells if
the margin is not tumor-free; a second attempted surgery is very difficult if not impossible.
All removed tissue should be submitted for histopathologic analysis. A thorough history
of the patient, clinical signs related to the tumor, suspected diagnosis, and description of surgical
excision margins must be given to the pathologist for evaluation. Edges of the submitted sample
should be painted to check for tumor-free margins, and the orientation of the mass can be marked
with suture tags or pinned to cardboard. In general, there is 30-40% shrinkage of tissue when it
is placed into formalin, and this should be taken into account when evaluating the margins
reported by the pathologist.