Information

Difference between taking tissue of cancer from secondary place or primary place


Are there any differences when a surgeon takes tissue from secondary place (for example from metastasis) rather then from primary place (from an organ where cancer is) for morphological research?


I would disagree a bit with the previous answer. There are absolutely differences between the metastasis and the primary tumor. One result of this is that people very rarely die of primary tumors, but rather from the metastases of those tumors. The primary tumors will be quite heterogeneous and contain largely cells that have not undergone steps necessary for migration like epithelial to mesenchymal transition. After cells have metastasized they will be separate from the original primary tumor, and contain unique genomes. Because this is the more 'progressed' group of cancer cells, these are often the cells that need to be targeted. So, determination of the proper treatment strategy should be done on the metastasized cells.


By definition, a cancer which has spread to another site via the circulatory or the lymphatic system (called metastasis) is malignant. If a surgeon takes it from a secondary site, it is malignant.

In the past, there were times that a cancer was so undifferentiated that to determine it's source was not possible. As science (particularly genetics) and technology continue to advance, tissue of origin is more easily determined.

Are there any differences when a surgeon takes tissue from secondary place rather then from primary place for morphological research?

Theoretically, it seems as it shouldn't, but it can happen at times, because, for example, a carcinoma may contain a mixed population of cancer cells, while the metastatic tumor may be of only one type.

For research purposes - which is different from diagnostics - it depends on the features most desired for research purposes.

In the past, there were times that a cancer was so undifferentiated that to determine it's source was not possible. As science (particularly genetics) and technology continue to advance, tissue of origin

NCI Dictionary of Cancer Terms
Multicenter Validation of a 1,550-Gene Expression Profile for Identification of Tumor Tissue of Origin


Difference between taking tissue of cancer from secondary place or primary place - Biology

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. Use the menu to see other pages.

Staging is a way of describing if and where a cancer has spread. Doctors use diagnostic tests, including CT scans and blood tests, to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and helps predict a patient's prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. For testicular cancer, an S is added to the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

Tumor (T): How large is the primary tumor? Where is it located?

Node (N): Has the tumor spread to the lymph nodes in the back of the abdomen (retroperitoneum)?

Metastasis (M): Has the cancer spread to other parts of the body? If so, where and how much?

Serum tumor marker (S): Are the serum tumor markers AFP, beta-hCG, and LDH (see Diagnosis) elevated? If so, how high are they?

The results are combined to determine the stage of cancer for each person. There are 3 stages of testicular cancer: stages I, II, and III (1, 2, and 3). The stage provides a common way of describing how advanced the cancer is so that doctors can work together to plan the best treatment. Stage I is the least advanced or earlier stage, and stage III is the most advanced or later stage. Patients with the least advanced stages are more likely to be cured and often need less aggressive treatment than patients with a more advanced stage.

Staging for testicular cancer can also be clinical or pathological:

Clinical staging is based on the results of tests other than surgery or biopsy, which may include physical examinations and imaging tests (see Diagnosis). For example, clinical stage II testicular cancer means that the retroperitoneal lymph nodes are enlarged when viewed with a CT or MRI scan.

Pathological staging is based on what is found during surgery. For example, pathological stage II testicular cancer means that cancer has been found when tissue removed from the retroperitoneal lymph nodes is examined under a microscope. In general, pathological staging provides the most information to determine a patient’s prognosis, but it is not always needed.

It may be helpful to note that nearly all people with testicular cancer are diagnosed by having a testicle removed. The difference between clinical staging and pathological staging in testicular cancer primarily depends on whether or not surgery was performed to remove retroperitoneal lymph nodes (this is called a retroperitoneal lymph node dissection or RPLND see Types of Treatment). Imaging scans can only show whether or not the lymph nodes are enlarged or if there is a mass somewhere. Normal-size lymph nodes may contain cancer, and enlarged lymph nodes may not contain cancer. Surgery or biopsies can prove whether cancer is present in a lymph node or mass. This means that people with clinical stage I cancer have had surgery to remove the cancerous testicle and there is no evidence of metastatic cancer on imaging studies, such as CT scans (see Diagnosis), and blood tests. People with pathological stage I cancer have no evidence of metastatic cancer in imaging scans and blood tests and have also had a RPLND that found no cancer in the lymph nodes. Similarly, people with clinical stage II cancer have enlarged retroperitoneal lymph nodes in imaging scans and people with pathological stage II cancer have cancerous lymph nodes found during surgery.

Here are more details on each part of the TNM system for testicular cancer:

Tumor (T)

Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Tumor size is measured in centimeters (cm). A centimeter is roughly equal to the width of a standard pen or pencil.

Stage may also be divided into smaller groups that help describe the tumor in even more detail. For testicular cancer, the T stage can only be determined when tissue removed during surgery is examined under a microscope. This means that the T stage is only determined after the testicle is removed, and the T stage is always a pathological stage and never a clinical stage. The “p” before the T stage indicates that it is a pathological stage. Specific tumor stage information is below.

pTX: The primary tumor cannot be evaluated. If the testicle(s) have not been surgically removed, the term "TX" is used.

pT0 (T plus zero): There is no evidence of a primary tumor in the testicles.

pTis: This stage describes germ cell neoplasia in situ (GCNIS). This is a precancerous condition in which there are germ cells that appear cancerous but are not yet behaving the way cancer cells do. GCNIS becomes cancer when the cells grow into parts of the testicle(s) where they do not normally belong.

pT1: The primary tumor is only in the testicle, which may include the rete testis. It has not grown into blood vessels or lymph vessels in the testicles. The tumor may have grown into the inner membrane layer surrounding the testicle, called the tunica albuginea. It has not spread to the outer membrane layer surrounding the testicle, called the tunica vaginalis.

For a pure seminoma, this stage is further divided based on the side of the tumor:

pT1a. The tumor is smaller than 3 centimeters (cm) in size.

pT1b. The tumor is 3 cm or larger in size.

pT2: The tumor is in the testicle, which may include the rete testis, and it has grown into 1 or more of the following parts of the testicle:

Blood vessels or lymphatic vessels in the testicle

The fatty tissue next to the epididymis called the hilar soft tissue

pT3: The tumor has grown into the spermatic cord.

pT4: The tumor has grown into the scrotum.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These small, bean-shaped organs help fight infection. Lymph is a fluid that flows from the different tissues and organs of the body and eventually drains into the bloodstream. It passes through specialized tubes called lymphatic vessels and is filtered along the way by the lymph nodes. Cancer cells often build up and grow in lymph nodes before they spread to other parts of the body. The first place the lymphatic fluid from the testicles drains to is the retroperitoneal lymph nodes located in the back of the abdomen in front of the spine, an area called the retroperitoneum. These are called the regional lymph nodes for testicular cancer. Lymph nodes in the pelvis, chest, or other parts of the body are called distant lymph nodes, even though the testicles are closer to the pelvis than to the retroperitoneum.

For testicular cancer, lymph nodes usually are not biopsied or removed. Instead, the N stage (lymph node stage) is most often estimated by using CT scans. N stage that is based on CT scans is the clinical stage. When the N stage is based on a biopsy or removal of the lymph nodes, it is the pathological stage. When a stage has been determined pathologically, the letter “p” is added as the first letter of the stage (for example pN1). The letter "c" stands for clinical stage.

NX: The regional lymph nodes cannot be evaluated.

cN0: There is no spread to regional lymph nodes as seen on imaging tests.

pN0: There is no cancer found in lymph nodes removed during a RPLND.

cN1: Imaging tests show signs that the cancer has spread to 1 or more lymph nodes in the retroperitoneum. None of the lymph nodes are bigger than 2 centimeters (cm).

pN1: There is cancer in 1 to 5 lymph nodes, and none are larger than 2 cm.

cN2: Imaging tests show at least 1 enlarged lymph node or lymph node mass in the retroperitoneum that is larger than 2 cm but not larger than 5 cm.

pN2: Either or both of the following conditions:

There is cancer in more than 5 lymph nodes, but none are larger than 5 cm.

There is cancer in at least 1 lymph node, and the largest lymph node or lymph node mass is between 2 cm and 5 cm in size.

cN3: Imaging tests show at least 1 enlarged lymph node or a lymph node mass in the retroperitoneum larger than 5 cm.

pN3: There is cancer in at least 1 enlarged lymph node or lymph node mass that is larger than 5 cm.

Metastasis (M)

The "M" in the TNM system describes whether the cancer has spread to other parts of the body, called distant metastasis. When testicular cancer spreads, it most commonly spreads to the lung and the lymph nodes of the chest, pelvis, and the base of the neck. More advanced stages may have spread to the liver and bones. Testicular cancer rarely spreads to the brain unless the primary tumor is a choriocarcinoma.

MX: Distant metastasis cannot be evaluated.

M0: The disease has not metastasized to distant lymph nodes or other organs.

M1: There is at least 1 distant metastasis.

M1a: There is cancer in the lungs or lymph nodes other than the retroperitoneal lymph nodes.

M1b: The cancer has spread to organs other than a lung. The lungs may or may not also be involved. For example, a testicular cancer that has spread to the liver or the bones is stage M1b.

Serum tumor markers (S)

Serum tumor markers also help to stage testicular cancer. Blood tests for tumor markers will be done before and after surgical removal of the testicle(s). Tumor marker levels usually decrease after the surgery. Generally, the levels need to be tested until they stop decreasing or begin to rise to determine the correct "S" stage. For patients who will receive chemotherapy, the tumor marker levels on the first day of chemotherapy are used to determine the risk group (see below).

SX: Tumor marker levels are not available, or the tests have not been done.

S0: Tumor marker levels are normal.

S1: At least 1 tumor marker level is above normal. LDH is less than 1.5 times the upper limit of the normal range, beta-hCG is less than 5,000 mIu/mL, and/or AFP is less than 1,000 ng/mL.

S2: At least 1 tumor marker level is substantially above normal. This means that LDH is 1.5 to 10 times the upper limit of the normal range, beta-hCG is 5,000 to 50,000 mIu/mL, and/or AFP is 1,000 to 10,000 ng/mL. None of the tumor markers is elevated high enough to qualify as S3 (see below).

S3: At least 1 or more tumor marker level is very highly elevated. This means that LDH is more than 10 times the upper limit of the normal range, beta-hCG is more than 50,000 mIu/mL, and/or AFP is more than 10,000 ng/mL.

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications and the S level information.

Stage 0: Refers to carcinoma in situ, also called intratubular germ cell neoplasia. (pTis, N0, M0, S0)

Stage I: Cancer is at any T level, and there is no evidence of spread to either lymph nodes or other organs. Serum tumor marker levels have not been done or are not available. (any T, N0, M0, SX)

Stage IA: The cancer is only in the testicle. It may have grown into the rete testis, but it has not grown into the epididymis, hilar soft tissue, or lymphatic or blood vessels in the testis. It has not spread to lymph nodes or distant sites. The tumor in the testis may have grown into the inner membrane surrounding the testis, called the tunica albuginea, but not the outer membrane, called the tunica vaginalis. Serum markers are normal. (pT1, N0, M0, S0)

Stage IB: The testicular tumor has grown into the epididymis, hilar soft tissue, tunica vaginalis, the blood or lymphatic vessels within the testicle, the spermatic cord, or the scrotum. The cancer has not spread to lymph nodes or distant sites. Serum markers are normal. (pT2, pT3, or pT4, and N0, M0, S0)

Stage IS: Cancer is of any T stage and has not spread to lymph nodes or distant sites. Serum markers remain higher than normal levels after the cancerous testicle has been removed. Stage IS non-seminoma testicular cancer is treated the same as stage III testicular cancer. Stage IS pure seminomas are rare and it is not known how they are best treated. (any T, N0, M0, and S1–S3)

Stage II: The cancer has spread to any number of regional lymph nodes but not to lymph nodes in other parts of the body or distant organs. Serum markers are unavailable. (any T, N1-N3, M0, SX)

Stage IIA: Cancer has spread to retroperitoneal lymph nodes, either clinical or pathological stage N1, but none are larger than 2 cm. If a lymph node dissection has been done, no more than 5 lymph nodes contain cancer. In addition, serum tumor marker levels are normal or only slightly high. There are no signs of cancer having spread anywhere other than the retroperitoneum. (any T, N1, M0, S0 or S1)

Stage IIB: Cancer has spread to lymph nodes in the retroperitoneum, and the largest lymph node with cancer or lymph node mass is between 2 cm and 5 cm in size. If a lymph node dissection has been done, cancer has spread to at least 1 lymph node (or lymph node mass) between 2 cm and 5 cm or to more than 5 lymph nodes, with none larger than 5 cm. Serum marker levels are normal or slightly high. There is no evidence of cancer having spread anywhere other than the retroperitoneum. (any T, N2, M0, S0 or S1)

Stage IIC: Cancer has spread to at least 1 lymph node (or lymph node mass) that is larger than 5 cm. Serum marker levels are normal or slightly high. There is no evidence of cancer having spread anywhere other than the retroperitoneum. (any T, N3, M0, S0 or S1)

Stage III: Cancer has spread to distant lymph nodes or to any organ. Serum tumor marker levels are unknown. (any T, any N, M1, SX)

Stage IIIA: Cancer has spread to distant lymph nodes and/or the lungs. Serum marker levels are normal or only mildly increased. (any T, any N, M1a, S0 or S1)

Stage IIIB: Cancer has spread to any lymph nodes and/or the lungs but not to any other organs. At least 1 serum marker is substantially elevated. (any T, N1–N3, M0, S2 or any T, any N, M1a, S2)

Stage IIIC: Either or both of the following:

At least 1 serum marker is extremely high, and the cancer has spread to at least 1 lymph node or organ. (any T, N1–N3, M0, S3, or any T, any N, M1a, S3)

The cancer has spread to an organ other than the lungs. (any T, any N, M1b, any S)

Recurrent: Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017), published by Springer International Publishing.

Later-stage testicular cancer: risk group classification

If the disease has spread to lymph nodes or other organs, the following system is used to classify a germ cell tumor into a good, intermediate, or poor risk group. This helps to determine the treatment plan and the likelihood of cure. Patients with a tumor in the intermediate and poor risk groups usually receive more chemotherapy than patients with a tumor in the good risk group.

The differences between good, intermediate, and poor risk are the same as the differences between stage IIIA, stage IIIB, and stage IIIC (above). Stage IIIA is the same as good risk, IIIB is the same as intermediate risk, and IIIC is the same as poor risk.

Good risk

Non-seminoma. The cancer has not spread to an organ other than the lungs and serum tumor marker levels are normal or slightly elevated, which means:

Seminoma. The cancer has not spread to an organ other than the lungs and AFP, any B-hCG, any LDH levels are normal.

Intermediate risk

Non-seminoma. The cancer has not spread to an organ other than the lungs and the serum tumor marker levels are intermediate, which means:

AFP between 1,000 and 10,000 ng/mL

B-hCG between 5,000 and 50,000 iU/L

LDH between 1.5 x ULN and 10 x ULN

Seminoma. The cancer has spread to an organ other than the lungs and AFP, any B-hCG, any LDH levels are normal.

Poor risk

Non-seminoma. The cancer has spread to an organ other than the lungs or the serum tumor marker levels are poor, which means:

AFP is 10,000 ng/mL or higher

B-hCG is 50,000 iU/L or higher

LDH is 10 x ULN or higher

Seminoma. There is no poor-risk category for seminoma.

Source: Journal of Clinical Oncology.

Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.


What is Primary Growth

The primary growth is the increase in the length of both shoot and root of a plant. It occurs due to continuous cell divisions in the apical meristem. This means the primary growth occurs in the apices of shoots and roots. Immediately after the cell division, the cells are elongated and differentiated to the relevant tissues. The cells produced by the apical meristem are called the primary meristem. The primary meristem is differentiated into the protoderm, ground meristem, and procambium, which give rise to the epidermis, ground tissue, and vascular bundles respectively.

Figure 1: Dicot Stem and Monocot Stem

The axillary shoots are developed by the parallel mitotic cell divisions in the cortex. The apical dominance refers to the diminishing of the growth of the axillary buds by the apical meristem. The cut off of the apical meristem gives a bushy shape to the plant. The increase of the length of the shoot allows the plant to absorb sunlight efficiently. Moreover, the increase in the depth of the root allows the plant to absorb water efficiently. The primary stem of monocots and dicots are shown in figure 1.


What is Secondary Growth?

After primary growth, lateral meristem becomes active and results in the formation of secondary permanent tissues. It is called secondary growth. The lateral meristems are the lateral vascular cambium and cork cambium. They are formed only on dicots. In monocots, there is no cambium. Therefore, there is no secondary growth. As a result of secondary growth, there is an increase in thickness or girth in stems and roots. In the stem, the intrafascicular cambium becomes active and cut off cells to the outside and inside. The cells that cut off to the outside become the secondary phloem while the cells on the inside become the secondary xylem.

Figure 02: Secondary Growth

In the meantime, parenchyma cells between adjacent vascular bundles also become meristematic and form the interfascicular cambium. The intrafascicular cambium and the interfascicular cambium join to form a cambial ring, which is the vascular cambium. The interfascicular cambium cuts off cells to the outside and inside. The outside cells become the secondary phloem while inside cells become the secondary xylem. The cambium contains fusiform initials and ray initials. Fusiform initials give rise to normal xylem and phloem. Ray initials give rise to parenchyma, which forms medullary rays.

As the numbers of cell layers inside increase, the cells outside become compressed and this results in the formation of another lateral meristem in the outer layers of the cortex. These become a ring of cork cambium. Cork cambium cuts off cells to the inside and outside. Cells that are cut off to the outside become suberized and form the cork. Cells that cut off to the inside form secondary cortex.


Difference Between Primary and Secondary Lymphoid Organs

The human immune system is an important system, which facilitates major defensive actions against the foreign particles and microorganisms. The tissue aggregates where leukocytes mature, differentiate, and proliferate are called the lymphoid organs. They are mainly composed of epithelial cells and stromal cells, arranged either into organs or accumulation of diffuse lymphoid tissues. Lymphoid organs are classified as primary and secondary lymphoid organs.

Primary Lymphoid Organs

Primary lymphoid organs include the thymus and bone marrow. They are the places where the B and T lymphocytes differentiate from stem cells therefore, called as the sites of lymphopoiesis. These organs were first discovered in birds, in which the maturation of B lymphocyte takes place in the bursa of Fabricius. Humans do not possess this organ. In humans, B lymphocytes mature and differentiate from hematopoietic stem cells in the fetal liver during the embryonic life. After birth, the maturation and differentiation of B cells take place in the bone marrow. Progenitor cells of bone marrow differentiate into T lymphocytes, once they migrate to the thymus. Thus, the major function of the thymus is to direct T lymphocytes to differentiate between self and nonself antigens.

Secondary Lymphoid Organs

Secondary lymphoid organs include the lymphoid nodes, Peyer’s patches, spleen, tonsils and adenoids. They are the sites where the antigen- driven proliferation and differentiation, and lymphocyte respond to pathogens and foreign antigens take place. Infectious organisms are likely to be found in these organs.

What is the difference between Primary and Secondary Lymphoid Organs?

• Primary lymphoid organs develop before secondary organs during the ontogeny.

• Primary lymphoid organs are the thymus and bone marrow, whereas secondary lymphoid organs are the lymphoid nodes, Peyer’s patches, tonsils, adenoids and spleen.

• Primary lymphoid organs are the site of maturation for T and B cells, whereas secondary lymphoid organs are the sites of cell function for mature T and B cells.

• Differentiation of lymphocytes is taken place in primary lymphoid organs while the interaction of immune cells with each other and antigen processing are taken place in secondary lymphoid organs.

• Primary lymphoid organs serve as the microenvironment for antigen- independent differentiation of lymphocytes, whereas secondary lymphoid organs serve as the microenvironment for attracting antigen- specific lymphocytes, facilitating the lymphocyte differentiation and distributing the differentiated effector cells or their products to other parts of the body.


2. Types of primary breast cancer

There are different types of breast cancer.

Breast cancer can be non-invasive (also called ‘in-situ’) or invasive.

Non-invasive breast cancer

Non-invasive breast cancer has not yet developed the ability to spread, either within the breast or to another part of the body.

Ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is an early type of breast cancer, sometimes called intraductal, non-invasive or pre-invasive cancer.

The cancer cells are inside the milk ducts (known as ‘in situ’) and have not yet developed the ability to spread, either through the ducts into surrounding breast tissue or to other parts of the body.

If DCIS is not treated, the cells may develop the ability to spread and become invasive breast cancer.

Invasive breast cancer

Most breast cancers are invasive. Invasive breast cancer has the potential to spread to other areas of the body. This doesn’t mean the cancer has or will spread to another part of the body, just that it is a possibility. Treatments aim to reduce the risk of this happening.

Invasive ductal breast cancer (of no special type)

Most breast cancers are invasive ductal breast cancers. Breast cancer cells started in the milk ducts and have spread to the surrounding breast tissue.

It’s also called breast cancer of no special type (NST) or not otherwise specified (NOS). This is because when the cancer cells are looked at under a microscope they have no distinct features that class them as a particular type.

Invasive lobular breast cancer

This is the second most common type of breast cancer, where cancer cells in the lobules (milk-producing glands) have spread into the surrounding breast tissue.

Inflammatory breast cancer

Inflammatory breast cancer is a rare, faster-growing type of breast cancer. It is called inflammatory because the skin of the breast looks red and inflamed. This is caused by breast cancer cells blocking the tiny lymph channels in the breast and the skin.

Paget’s disease of the breast

Paget’s disease of the breast is an uncommon type of breast cancer that causes change to the skin of the nipple, similar to eczema.

Other types of breast cancer

There are several other rare special types of breast cancer. These include:


Mohs Surgery

Mohs surgery is considered the most effective technique for treating many basal cell carcinomas (BCCs) and squamous cell carcinomas (SCCs), the two most common types of skin cancer. Sometimes called Mohs micrographic surgery, the procedure is done in stages, including lab work, while the patient waits. This allows the removal of all cancerous cells for the highest cure rate while sparing healthy tissue and leaving the smallest possible scar.

It began as a technique called chemosurgery, developed by Frederic E. Mohs, MD, in the late 1930s, but was not widely known. In the mid 1960s, Perry Robins, MD, studied the procedure with Dr. Mohs, and recognized that it had great potential for the field of dermatology. He brought the technique to NYU, where he established the first fellowship training program to teach dermatologists this skin cancer surgery. Dr. Robins helped advance the procedure into what is now called Mohs surgery and went on to teach and promote it around the world.

In partnership with
The Advantage of Mohs

CURE RATE
for a skin cancer that has not been treated before

Who performs the procedure?

Mohs surgery is performed by doctors who are specially trained to fulfill three roles:

  1. as the surgeon who removes the cancerous tissue
  2. as the pathologist who analyzes the lab specimens
  3. as the surgeon who closes or reconstructs the wound

Advantages of Mohs surgery

Efficient, cost-effective treatment

Precise results

  • Physician examines 100% of tumor margins
  • Spares healthy tissue
  • Leaves the smallest scar possible

The highest cure rate

  • Up to 99% for a skin cancer that has not been treated before
  • Up to 94% for a skin cancer that has recurred after previous treatment

What happens during Mohs surgery

The procedure is done in stages, all in one visit, while the patient waits between each stage. After removing a layer of tissue, the surgeon examines it under a microscope in an on-site lab. If any cancer cells remain, the surgeon knows the exact area where they are and removes another layer of tissue from that precise location, while sparing as much healthy tissue as possible. The doctor repeats this process until no cancer cells remain.

Step 1: Examination and prep

/>Depending on the location of your skin cancer, you may be able to wear your street clothes, or you may need to put on a hospital gown. The Mohs surgeon examines the spot where you had your biopsy and may mark it with a pen for reference. The doctor positions you for best access, which may mean sitting up or lying down. A surgical drape is placed over the area. If your skin cancer is on your face, that may mean you can’t see what’s happening, but the doctor talks you through it. The surgeon then injects a local anesthesia, which numbs the area completely. You stay awake throughout the procedure.

Step 2: Top layer removal

/>Using a scalpel, the surgeon removes a thin layer of visible cancerous tissue. Some skin cancers may be “the tip of the iceberg,” meaning they have roots or extensions that aren’t visible from the surface. The lab analysis, which comes next, will determine that. Your wound is bandaged temporarily and you can relax while the lab work begins.

Step 3: Lab analysis

/>The surgeon cuts the tissue into sections, color codes them with dyes and draws a map of the surgical site. In the lab, a technician freezes the divided tissue, then cuts very thin horizontal slices like a layer cake. The slices are placed on microscope slides, stained and covered. This meticulous process takes time.

Step 4: Microscopic examination

Using a microscope, the surgeon examines all the edges and underside of the tissue on the slides and, if any cancer cells remain, marks their location on the map. The physician then lets you know whether you need another layer of tissue removed.

Step 5: Second layer removal

/>Back in the operating room, the surgeon injects more anesthesia if needed and removes another layer of skin, precisely where the cancer cells remain, based on the map. Then, while you wait, the lab work begins again. This entire process is repeated as many times as needed until there are no more cancer cells.

Step 6: Wound repair

Once the site is clear of all cancer cells, the wound may be left open to heal or the surgeon may close it with stitches. This depends on its size and location. In some cases, a wound may need reconstruction with a skin flap, where neighboring tissue is moved into the wound, or possibly a skin graft. In some cases, your Mohs surgeon may coordinate the repair of your wound with another specialist such as a plastic surgeon, oculoplastic surgeon or hand surgeon. In most instances, however, the Mohs surgeon will repair the wound immediately after obtaining clear margins.

Step 7: Finishing up

If more than one or two rounds are needed, the entire process can take up to several hours, so be prepared for that. It’s worth it, though, because this precise technique has the highest cure rate of any treatment method and can save the greatest amount of healthy tissue, leaving the smallest scar possible. Carefully follow your doctor’s instructions for wound care, scar care and follow-up to achieve the best outcome.


8 breast biopsy questions, answered

Getting a breast biopsy? You might be wondering what it is and how it works.

A breast biopsy is a diagnostic procedure in which a doctor removes a small amount of breast tissue to examine under a microscope. If the tissue sample shows cancer, the physician can have it analyzed further to provide the most accurate diagnosis — a critical first step in getting patients the best treatment possible for their particular type of breast cancer.

A biopsy may be ordered when a mammogram or other breast imaging (such as an ultrasound) reveals an abnormality or you feel a lump in your breast, or when a physician notices something suspicious (such as dimpling or a change in skin texture) during a clinical exam.

We spoke with Marion Scoggins, M.D., to learn more. Here’s what she had to say.

What are the types of breast biopsies, and how are they different?

There are two basic types of breast biopsy: surgical and needle. A breast biopsy done surgically through an incision in the skin is called a surgical breast biopsy. A breast biopsy done by inserting a needle through the skin is called a breast needle biopsy.

There are two main types of breast needle biopsy:

  • fine needle aspiration, which uses a thin, hollow needle attached to a syringe, and
  • core needle biopsy, which uses a larger needle that removes a small, tube-shaped piece of tissue with a spring-loaded device or a vacuum-assisted device.

Because it’s important to pinpoint areas of concern and pull tissue from those exact spots, doctors typically use an ultrasound — or a mammogram or MRI, in some cases — to guide a breast needle biopsy. A mammogram-guided biopsy is also called a stereotactic biopsy.

At MD Anderson , we place small metallic markers called “clips” in the breast at the time of a breast needle biopsy and leave them there. This allows our radiologists and surgeons to know the exact location of the biopsy, in case we need to remove something else from the area where a tissue sample was taken.

How painful is each kind of biopsy, and how long does it take to recover?

Local anesthesia is given for breast needle biopsies, which makes them tolerable and comfortable for most patients.

The recovery time is typically very short, but may vary depending on the amount of bleeding and/or bruising. A core needle biopsy is more likely to result in bruising than a breast fine needle biopsy. Bruising from a breast biopsy may take several weeks to completely resolve. Your doctor can discuss expected recovery times and what to do to take care of the area that’s been biopsied.

Do any breast biopsies require general anesthesia or an overnight stay in the hospital?

A breast needle biopsy is done with local anesthesia, so it does not require general anesthesia.

A surgical breast biopsy may require general anesthesia, but typically won’t require an overnight hospital stay.

How do doctors determine which biopsy is best for a particular patient?

If there’s an abnormal finding on your mammogram or breast ultrasound that we need to biopsy, a radiologist will determine the most appropriate type of biopsy, based on how much tissue is needed to get an accurate diagnosis and the question doctors seek to answer with the biopsy.

Is there ever a time when a patient should ask their doctor for a biopsy (or for a specific type)?

A biopsy is only recommended if there’s a suspicious finding on a mammogram, ultrasound or MRI, or a concerning clinical finding. If a scan is normal and there are no worrisome symptoms, there’s no need for a biopsy.

If you do need a biopsy, your doctor should discuss which type of biopsy is needed and why. Your doctor can answer any questions you have and explain the procedure and its purpose, as well as its benefits, risks and alternatives.

What are the potential risks of a breast needle biopsy?

As with any medical procedure, there are known risks and benefits with a breast needle biopsy. It is possible that patients may have pain, bleeding or infection. So, be aware of these potential complications and discuss them with your doctor before the procedure.

Some patients express concerns about whether a breast needle biopsy might cause cancer to spread. But there’s no evidence of a negative long-term effect from a breast needle biopsy. And the benefits of a breast needle biopsy — as opposed to a surgical biopsy or no biopsy at all — outweigh the risks.

Why should you have your biopsy done at MD Anderson?

All MD Anderson does is cancer and our doctors perform all different types of breast biopsies on a daily basis. Each year, our breast radiologists perform more than 2,000 ultrasound-guided biopsies, 750 stereotactic biopsies and 250 MRI-guided breast biopsies, on average. Our radiologists are fellowship-trained breast-imaging specialists, which means they’ve received additional sub-specialty training after completing residency. And our biopsies are interpreted by pathologists who specialize in breast cancer.

If a biopsy reveals cancer, our team of oncologists, radiologists, surgeons and pathologists work together to develop individualized treatment plans for the patient. This approach ensures that patients have access to any additional support services they might need, such as physical therapists, dietitians and social work counselors.

Anything else readers should know about breast biopsies?

Just because you need a breast biopsy doesn’t mean you have cancer. In fact, most breast biopsies turn out to be benign (not cancerous). So don’t worry if it takes several days to receive the results of your breast biopsy. This is typical, and it simply means we are doing our job and ensuring you get the most accurate results.


Ductal Carcinoma In Situ (DCIS)

Ductal carcinoma in situ (DCIS) is non-invasive breast cancer. Ductal means that the cancer starts inside the milk ducts, carcinoma refers to any cancer that begins in the skin or other tissues (including breast tissue) that cover or line the internal organs, and in situ means "in its original place." DCIS is called "non-invasive" because it hasn’t spread beyond the milk duct into any normal surrounding breast tissue. DCIS isn’t life-threatening, but having DCIS can increase the risk of developing an invasive breast cancer later on.

When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. Most recurrences happen within the 5 to 10 years after initial diagnosis. The chances of a recurrence are under 30%.

Women who have breast-conserving surgery (lumpectomy) for DCIS without radiation therapy have about a 25% to 30% chance of having a recurrence at some point in the future. Including radiation therapy in the treatment plan after surgery drops the risk of recurrence to about 15%. Learn what additional steps you can take to lower your risk of a new breast cancer diagnosis or a recurrence in the Lower Your Risk section. If breast cancer does come back after earlier DCIS treatment, the recurrence is non-invasive (DCIS again) about half the time and invasive about half the time. (DCIS itself is NOT invasive.)

According to the American Cancer Society, about 60,000 cases of DCIS are diagnosed in the United States each year, accounting for about 1 out of every 5 new breast cancer cases.

There are two main reasons this number is so large and has been increasing over time:


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United States. National Cancer Institute. National Institutes of Health. "Endometrial Cancer Treatment." June 12, 2019. <https://www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq>.

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Endometriosis

Endometriosis implants are most commonly found on the ovaries, the Fallopian tubes, outer surfaces of the uterus or intestines, and on the surface lining of the pelvic cavity. They also can be found in the vagina, cervix, and bladder. Endometriosis may not produce any symptoms, but when it does the most common symptom is pelvic pain that worsens just prior to menstruation and improves at the end of the menstrual period. Other symptoms of endometriosis include pain during sex, pain with pelvic examinations, cramping or pain during bowel movements or urination, and infertility.


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