Textbook of Medical-Surgical Nursing 3e

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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

ASSESSMENT TNM classification system

CHART 11-3

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

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, www.springer.com.

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