Updated: 10/4/2016

Guided Needle Biopsy of Malignant Lesion

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • history
  • past history of cancer or radiation
  • prior treatments
  • pre-existing pain
  • smoking or chemical exposure
  • constitutional symptoms
  • fever
  • physical exam
  • notes lymph node involvement, lumps/nodules

2

Interprets basic imaging studies

  • describe the radiographic appearance
  • osteolytic
  • osteoblastic

3

Prescribes and manages nonoperative treatment

  • understand when to have the patient back to clinic for follow-up
  • understand when to order new radiographic imaging studies

4

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • check radiographs
  • discuss result of the biopsy
  • plan definitive surgery
  • diagnose and management of early complications
  • infection
  • DVT/PE
  • wound breakdown
  • neurovascular compromise
  • postop: 4-6 week postoperative visit
  • check radiographs
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Appropriately orders and interprets advanced imaging studies/lab studies

  • 3D radiographic studies to include CT
  • MRI
  • lab studies
  • SPEP/UPEP
  • PSA
  • other tumor markers

2

Recommends complex non-operative treatment

  • RFA or cryoablation
  • Bisphosphonates
  • Kyphoplasty or vertebroplasty

3

Nonoperative treatment

  • infection
  • wound breakdown
  • DVT/PE)

4

Pre-operative preparation and consultation

  • onc
  • rad onc
  • counseling
C

Preoperative H & P

1

Obtains history and performs basic physical exam

  • history
  • pain and function
  • past medical/surgical/social/family history
  • review of systems
  • physical exam
  • heart
  • lungs
  • extremity exam
  • range of motion
  • strength
  • sensation
  • skin changes
  • tenderness
  • screen medical studies to identify and contraindications for surgery

2

Orders basic imaging studies

  • radiographs
  • AP/lateral of the lesion
  • Joint above and below the lesion

3

Prescribe non-operative treatment

  • protected weightbearing
  • bracing
  • no intervention

4

Perform operative consent

  • describe complications of surgery including
  • Infection
  • Inadequate specimen
  • Wound complications
  • Neurovascular compromise
  • Tumor progression
  • DVT/PE
  • Pneumonia

Operative Techniques

E

Preoperative Plan

1

Radiographic templating

  • template part of the lesion to be biopsied
  • plan the biopsy tract

2

Execute surgical walkthrough

  • describe the steps of the procedure to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • guiding needle

2

Room setup and equipment

  • Standard OR table
  • fluoroscopy

3

Patient positioning

  • depends on the area of the lesion
G

Biopsy Tract

1

Mark incision over lesion

  • define what part of the lesion needs to be biopsied
  • plan the safest anatomic route to the lesion

2

Make a longitudinal incision

  • transverse incisions are contraindicated because of the need for a wider resection at the time of surgery
H

Entry Hole to Bone

1

Create cortical window

  • oblong holes with rounded edges have the greatest residual strength
I

Remove Tissue

1

Use a knife or curette to remove the tissue

  • care must be taken not to crush the sample

2

Send frozen section

  • ensure that the obtained tissue is adequate
J

Hemostasis

1

Seal the cortical window

  • plug the window with methacrylate to limit hematoma formation
K

Wound Closure

1

Perform layered closure

  • use 3-0 vicryl for subcutaneous tissue
  • use 3-0 nylon for skin

2

Place dressings

  • place soft dressings over incision

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive post operative orders

  • pain control
  • advance diet as tolerated
  • check appropriate labs
  • wound care
  • remove dressings POD 2
  • IV fluids
  • nutrition
  • appropriate medical management and medical consultation
  • follow up with pathology for findings of biopsy
  • inpatient physical therapy
  • weight bear as tolerated

2

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
R

Complex Patient Care

1

Recommends appropriate biopsy including biopsy alternatives and appropriate techniques

  • understand role of open biopsy vs needle biopsy

2

Develops unique, complex post-operative management plans

3

Discusses prognosis and end of life care with patient and family

 

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