A patient presented with a well-circumscribed lesion of her tongue that had been interfering with eating as it grew. After an in-office biopsy that diagnosed it as metastatic breast cancer, Dr. Liana Puscas and her resident perform a partial glossectomy to alleviate the patient’s symptoms.
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- Patient Introduction
- Resection of Lesion
- Measure Lesion Dimensions and Margins
- Specimen Orientation
- Specimen Margins
- Long-acting Local Anesthetic
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarantee their complete accuracy.
Do we want to intro our patient here? This may be too big. Do you think a molt would help us out first? No it’s okay, I think we are good right there. Can I have something to point with please?
This is actually where I took the biopsy from. Before I took the biopsy it was perfectly round like that and the interesting thing about it is that you can see it's actually quite well encapsulated. It's not… it wasn't actually ulcerated. So it's just… I actually was not expecting the diagnosis of metastatic breast cancer. I was actually thinking it was something like a leiomyoma or potentially a small salivary gland tumor. I was actually expecting something more benign just because of its appearance, because it doesn't have a typical appearance of Swaim and it really actually was not painful for her. It interfered with her eating a little bit and with articulation and a little bit of some pain but only when you just directly touched it but in general it wasn't hurting her.
Can I see Debakey's please? I was hoping for something benign and then it came back as metastatic breast cancer which was… How much of a margin do you want to get around this? We need to get a centimeter.
Can I see a measuring tape real quick. Let’s get some dimensions on this. And then you can see she's already had a good blanche of her tongue from where I did the local. Centimeter and a half and if we are counting where you biopsy, I think about a centimeter and a half all the way around. So you want to get centimeter margins? Yeah I think we need to because I just don’t want this to come back. I'm I'm I'm going to just kind of touch in a couple places to get myself a… Can I have the Army-Navy please? I think that's a little close here. Yeah. That’s better. Go right above the teeth, yeah. Good.
Alright go for it now. Start here and work our way around. Where’s that Army Navy? Can one of you get the smoke please? Just suck the smoke Why don't you use… Yeah or just use the towel clamp. Can I have a rat's tooth? Now I can pick it up for you. No you have to hold the smoke. No not you, them. One of the two of them can hold the suction. Can one of you guys hold the suction? And you have a rat’s tooth?
This doesn’t look like it extends deeply does it. It does not. Doesn't feel like it. I think that’s good. I don’t think you want to go anymore superficial than that though, and watch here’s your incision on the other side.
Can we make the room cooler please? Suction there. Do you have a bipolar? Who has the pedal?
And you don't need to go any deeper than that cause if you look a centimeter… Yes, this way toward me a little bit. Can you take the suction from me please? Thank you. Pinning it? Uh no. Bipolar. Suction. Okay. Will you hold her lower lip out I don't want her to get burned? There we go. I just confirm that we're not undercutting on this side.
Do you have a 3-0 or 4-0 silk I can use for marking? I have a 2-0. That's fine. So the name of this specimen is left lateral tongue stitch anterior. Yes. Is that for frozen? No this is permanent.
Do you want to take frozen margins? I do want to take frozen margins. Can I see DeBakey’s please? Do just want me to do four quadrants? And then can I have some Stevens please?
Can you cut this please? No down here is fine, underneath. Yup.
The first frozen section margin is going to be anterior dorsal. Yes ma’am. Yes this is all left lateral tongue. Yes. Here's the specimen. Can we get a little rinse please on the instruments? Just some saline or something.
No. These are for frozen section these are frozen sections. You need to call the research people to come and get whatever they need to from the main specimen. That's usually how they do it. Here's a pair of pickups with teeth.
Melissa, the next the next specimen is going to be posterior dorsal. Just make sure I don’t have too much char in there. That’s part of it. Just call the next one, no, call the next one just posterior. And we'll go from there to there? Yeah because we've already done… that way you get the proportion the same. This next one is going to be left lateral tongue posterior. Get a little rest on your pickups and instruments. Rinse. We do that to make sure that any potential malignant cells aren’t contaminating our other specimens.
I am sorry Melissa, what did you say? Correct. These are all left lateral tongue because that’s the name of the specimen. And then we have anterior dorsal, posterior dorsal, posterior. The next one is going to be ventral anterior and then ventral posterior. That’s the rest of the posterior specimen. Correct. And then I will take a rinse please. Then we have two more. We will have ventral anterior and ventral posterior. Take the anterior first then? Yes.
About right there. Yup that’s good. This is the ventral anterior specimen. And then a rinse, and then the last one ventral posterior. Again all of them left lateral tongue and then just the names of the individual margins. There to there. Okay this is the ventral posterior. And then I will see the bipolar please. Suction. Watch her lip. Do you want to close with vicryl or kromex?
I think vicryl is good because it’s a decent size. I might just do some horizontal mattress sutures just to… for the tensile strength. Do you think that’s ok? That’s why I want to use the vicryl rather than the kromex just because it’s one thing to do it on the mucosa on something that doesn’t move as much, but your tongue moves all the time when you speak and when you are eating. So if you want the wound to stay closed you really need to use something like vicryl, because unless it’s a very small biopsy I think the chances are much higher that things will open up if you just use kromex rather than vicryl.
We can go ahead and close while we are waiting on the frozens. Yes. Can we have the vicryl please? Do you have a 2-0 vicryl?
Do you have it on a taper needle? Can I have a pair of DeBakey’s please? Oh hang on, I am going to use something else. Can I have the Army Navy again please? Hang out on you want to travel a little more. Yeah that’s it. There you go. I’ll come back and get that front part. Scissors please.
Why don’t you start up top? It might make it easier that way you can just backhand it. That way you can sew with the knot on top. I think it will be easier for you, plus I am thinking if you put the knot on top where she doesn’t have any teeth it won’t bother her as much. It won’t get involved with the teeth or get caught in between. Well I also don’t want her complaining “take these out” before she is healed. Patients tend to play with them all the time when they are in their mouth.
Now if we had to do some you know very large cancer resection it would not be worth it. But this is pretty low morbidity. She should heal quickly and this will help her to feel better especially when you get primary closure on something like this to pain afterwards as much as we've been like an open granulating wound.
Yes, yes it was it was nice and superficial so we don't have to worry about cranial nerve 12 and injuring that. This lady has a history of metaplastic breast cancer and it has metastasized to her tongue so these are just margins. We want to make sure we got it all. I think we did but… Now could she pop up with another lesion in 3 months? Yes, and I think at that point, that's a different conversation.
Can I see another vicryl please? Do you want me to run anything on the surface at the end? Or do you just want to leave it kinda everted. I think it'll be fine. Okay. I think you need two more and then the one up front.
It is just the history of it. The oncologist is the one who told me she said that metaplastic metaplastic breast cancer just doesn't respond very well.
Here let me hold this. Yeah that’s actually going to be more advantageous. This is it… this is a first for me I've taken care of patients with renal cell cancer that has metastasized to the tongue, but not breast cancer. This was actually more common than I was expecting it. Yes, although I… still uncommon but more more than I expected.
Quite embedded in there. I’ll hang out and wait on the frozens. Can we have some irrigation please? Let’s protect it. Then can we get some marcaine please? You just want to go in and inject along the back from each side. Yup. All the way around.
We are now injecting quarter percent marcaine plain for post-operative analgesia. The marcaine has a much longer Half-Life than a lidocaine and so patients will often do well the day of surgery if you use something long acting like marcaine. Works very well for patients who just undergone any kind of oral or oropharyngeal procedures such as tonsillectomy. Maybe a little in the back there. I used five.
Her tongue is a little swollen I think from the marcaine and from the lidocaine that we gave her. She got decadron preoperatively, so we should be ok. What we can also do is get her to sit up and that may also help with the… We can lower the bed and then put her in some reverse Trendelenburg that would be great. And then do we also have some... just a second in case we need to get more some somewhere… Bacitracin please?
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