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Unit 3
Applying concepts from the nursing process
lymph node staging in selected cases of melanoma and breast
cancer (Chen et al., 2006).
Biopsy types
The three most common biopsy methods are the excisional,
incisional and needle methods (Szopa, 2005). The choice of
biopsy method is based on many factors. Of greatest impor-
tance is the type of treatment anticipated if the cancer diag-
nosis is confirmed. Definitive surgical approaches include the
original biopsy site so that any cells disseminated during the
biopsy are excised at the time of surgery. Nutrition and haema
tological, respiratory, renal and hepatic function are consid-
ered in determining the method of treatment as well. If the
biopsy requires general anaesthesia and if subsequent surgery is
likely, the effects of prolonged anaesthesia on the patient are
considered. The patient and family are given an opportunity
to discuss the options before definitive plans are made. The
nurse, as the patient’s advocate, serves as a liaison between the
patient and the doctor to facilitate this process. Time should be
set aside to minimise interruptions. Time should be provided
for the patient to ask questions and for thinking about all that
has been discussed.
Excisional biopsy is most frequently used for easily accessi-
ble tumours of the skin, breast, upper and lower gastrointestinal
tract, and upper respiratory tract. In many cases, the surgeon
can remove the entire tumour and surrounding marginal tissues
as well. This removal of normal tissue beyond the tumour area
decreases the possibility that residual microscopic disease cells
may lead to a recurrence of the tumour. This approach not
only provides the pathologist who stages and grades the cells
with the entire tissue specimen but also decreases the chance
of seeding the tumour (disseminating cancer cells through
surrounding tissues).
Incisional biopsy is performed if the tumour mass is too
large to be removed. In this case, a wedge of tissue from the
tumour is removed for analysis. The cells of the tissue wedge
must be representative of the tumour mass so that the patholo-
gist can provide an accurate diagnosis. If the specimen does not
contain representative tissue and cells, negative biopsy results
do not guarantee the absence of cancer.
Excisional and incisional approaches are often performed
through endoscopy. In these procedures, an endoscope with
intense lighting and an attached multichip mini-camera is
inserted through a small incision into the body. Surgical
incision, however, may be required to determine the anatom-
ical extent or stage of the tumour. For example, a diagnostic
or staging laparotomy, the surgical opening of the abdomen to
assess malignant abdominal disease, may be necessary to assess
malignancies such as gastric cancer.
Needle biopsies are performed to sample suspicious masses
that are easily accessible, such as some growths in the breasts,
thyroid, lung, liver and kidney. Needle biopsies are fast, rela-
tively inexpensive and easy to perform and usually require only
local anaesthesia. In general, the patient experiences slight and
temporary physical discomfort. In addition, the surrounding
tissues are disturbed only minimally, thus decreasing the likeli-
hood of seeding cancer cells. Needle aspiration biopsy involves
aspirating tissue fragments through a needle guided into an
area suspected of bearing disease. Occasionally, radiological
imaging, computerised tomography (CT) scanning, ultraso-
nography or magnetic resonance imaging is used to help locate
the suspected area and guide the placement of the needle. In
interrelate is important in understanding the rationale and
goals of treatment.
Surgery
Where possible, surgical removal of the entire cancer remains
the ideal and most frequently used treatment method. The
specific surgical approach, however, may vary for several
reasons. Diagnostic surgery is the definitive method of iden-
tifying the cellular characteristics that influence all treatment
decisions. Surgery may be the primary method of treatment, or
it may be prophylactic, palliative or reconstructive.
Diagnostic surgery
Diagnostic surgery, such as a
biopsy
, is usually performed to
obtain a tissue sample for analysis of cells suspected to be
malignant. In most instances, the biopsy is taken from the
actual tumour.
In some situations, it is necessary to biopsy lymph nodes
that are near the suspicious tumour as many cancers can
spread (metastasise) from the primary site to other areas of
the body through the lymphatic circulation. Knowing whether
adjacent lymph nodes contain tumour cells helps surgeons
plan for systemic therapies instead of, or in addition to, surgery
in order to combat tumour cells that have gone beyond the
primary tumour site. The use of injectable dyes and nuclear
medicine imaging can assist the surgeon in identifying lymph
nodes (sentinel nodes) that process lymphatic drainage for
the involved area. Sentinel lymph node biopsy (SLNB),
also known as sentinel lymph node mapping, is a minimally
invasive surgical approach that in some instances has replaced
more invasive lymph node dissections (lymphadenectomy)
and associated complications such as lymphoedema and
delayed healing. SLNB has been widely adopted for regional
ASSESSMENT
TNM classification system
T
The extent of the primary tumour
N
The absence or presence and extent of regional lymph
node metastasis
M
The absence or presence of distant metastasis
The use of numerical subsets of the TNM components
indicates the progressive extent of the malignant disease.
Primary tumour (T)
TX Primary tumour cannot be assessed
T0 No evidence of primary tumour
Tis Carcinoma in situ
T1, T2, T3, T4 Increasing size and/or local extent of the primary
tumour
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1, N2, N3 Increasing involvement of regional lymph nodes
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
CHART
11-3
Used with the permission of the American Joint Commission on
Cancer (AJCC), Chicago, Illinois. The original source is by Edge,
Byrd and Compton (Eds) (2010), AJCC cancer staging manual
(7th ed.), Springer Science and Business Media LLC,
