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Surgery Review 5

SR 5: Cardiothoracic, Vascular, Breast

QuestionAnswer
What is the embryological origin of the breast? Ectoderm milk streak
Which artery supplies 60% of total breast mass with blood flow? Internal mammary artery
What is Batson’s plexus? Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine
Which quadrant of the breast can drain to internal mammary nodes? Any quadrant
Describe the innervation to the pectoralis muscles Medial pectoral nerve to pec major and minor; lateral pectoral nerve to pec major only
What biopsy findings in fibrocystic disease of the breast have an increased cancer risk? Atypical ductal or lobular hyperplasia
What is the most common bacteria in a breast abscess? S. aureus
What are common causes of infectious mastitis in a non-lactating woman? Actinomyces, tuberculosis, syphilis, or autoimmune diseases (SLE). May need to rule out necrotic cancer with an incisional biopsy including skin
What causes noncyclical mastodynia, nipple retraction, and creamy nipple discharge? Periductal mastitis (mammary duct ectasia or plasma cell mastitis) – dilated mammary ducts, inspissated secretions, and marked periductal inflammation
What is Poland’s syndrome? hypoplasia of chest wall, amastia, hypoplastic shoulder, and no pectoralis muscle
What is the treatment for mastodynia? Danazol, OCPs, NSAIDs, bromocriptine, and/or evening primrose oil. Make sure to discontinue caffeine, nicotine, and methylxanthines
What is Mondor’s disease? What is the treatment? thrombophlebitis of superficial vein of breast. Cord like mass laterally. Treat with NSAIDS
What is the most common cause of bloody nipple discharge? Intraductal papilloma – no risk of CA
What is the most likely diagnosis of a firm, rubbery, painless and mobile breast mass? Treatment? Fibroadenoma. If <30 – FNA or core biopsy; if >30 excisional biopsy to ensure diagnosis
What % of DCIS develop invasive cancer? 50-60% in ipsilateral breast
What is significant about the comedo subtype of DCIS? Most aggressive subtype, has necrotic areas, high risk of microinvasion and recurrence. Treat with total mastectomy
What % of LCIS develop invasive cancer? 30-40% in either breast
What is the difference pathophysiologically in cancer risk between DCIS and LCIS? DCIS is a precursor to cancer LCIS is a marker of risk
What are the BI-RADS classifications and associated recommendations? 1 – Negative (routine screening) 2- Benign finding (routine screening) 3 – Probably benign finding (short interval follow-up) 4 – Suspicious abnormality (consider biopsy) 5 – Highly suggestive of malignancy (appropriate malignancy workup and treatment
What are the locations of the axillary node levels? I – lateral to, II – beneath, and III – medial to pectoralis minor muscle
Where are Rotter’s nodes? Between pectoralis major and minor muscles
Describe the "T" staging of breast cancer T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = skin or chest wall involvement
Describe the "N" staging of breast cancer N1 = ipsilateral lymph nodes (1-3 LN on path) N2 = fixed or matted LN (4-9 LN on path) N3 = infraclavicular, supraclavicular, or internal mammary (>10 LN on path)
Decribe the staging of breast cancer (TNM) Stage I = T1 Stage IIA = T1N1 or T2N0; IIB = T2N1, T3N0 Stage IIIA = T1-3 and N2, or T3N1; IIIB = T4N0-2; IIIC = Any T N3
How does hormone receptor status in breast cancer affect prognosis? ER+PR+ > ER-PR+ > ER+PR- > ER-PR-
What genes are associated with breast cancer? p53, bcl-2, c-myc, c-myb, her2neu
What are Hagensen’s criteria for unresectability of breast cancer (Hagensen’s Grave Signs)? Skin ulceration, edema of <1/3rd of skin of breast, fixation of tumor to chest wall, axillary nodes >2.5cm, fixed axillary nodes
What are the gene mutations BRCA I and BRCA II associated with? BRCA I – ovarian (50%) and endometrial cancer (consider TAH / BSO), BRCA II – male breast cancer
What is significant about dermal lymphatic invasion on pathology after breast biopsy? Sign of inflammatory breast cancer
What are absolute contraindications to breast-conserving therapy requiring radiation? Prior radiation to breast/chest wall, Radiation therapy during pregnancy, Diffuse suspicious or malignant appearing microcalcifications, Widespread disease not able to be incorporated by local excision, Positive margins
What are the indications for RT after mastectomy? >4 nodes, skin or chest wall involvement, +margins, T3 or T4 tumor, N2 or N3 nodes
What is Stewart-Treves syndrome? Angiosarcoma arising from chronic lymphadema, often as a complication after mastectomy. Presents as a purplish mass on arm ~10 yrs s/p MRM
What is the chance of recurrence with lumpectomy and XRT? 10% (usually within 2 years)
What are the indications for chemotherapy in breast cancer? >1 cm tumor or positive nodes (except postmenopausal women with positive estrogen receptors -> tamoxifen)
What is Paget's disease of the breast? Treatment? Scaly skin lesion on nipple, suggesting underlying DCIS or ductal CA; Rx - MRM if cancer present, simple mastectomy if not
What % of Phyllodes tumor are malignant? 10% (based on mitoses per high-power field >5-10)
What is the treatment for Phyllodes tumor? Wide local excision, rarely mastectomy. No axillary node dissection necessary (spread is hematogenous, not lymphatic)
What is the mechanism of Tamoxifen? Selective estrogen receptor modulator (SERM)
What is the mechanism of letrozole (Femara) and anastrozole (Arimidex)? aromatase inhibitor
What are the risks and benefits of tamoxifen? Decreases short-term risk of breast cancer 50-60%, 1% risk of blood clots, 0.1% risk of endometrial cancer
What are the risks and benefits of anastrozole (Arimidex)? More effective than tamoxifen, particularly effective in ER+ PR-, side effects of bone loss and joint aches
What is the most common cause of hypercalcemia in breast cancer? Parathyroid Hormone Related Peptide (PTHrP)
Describe the relevant anatomy of the diaphragm T8 - vena cava; T10 - esophagus + vagus; T12 - aorta + thoracic duct
What is the course of the thoracic duct? Runs on right side, crosses midline at T4-5, drains into left subclavian/internal jugular vein junction
What are the accessory muscles of respiration? SCM, levators, serratus posterior, and scalenes
What is the difference between the two types of pneumocytes? Type I: functional gas exchange, Type II: produce surfactant (1%)
What is the preoperative FEV1 recommended for a: wedge resection? lobectomy? pneumonectomy? 0.6L; 1L; 2L
What is the required FEV1, DLCO, and FVC required after lung resection? FEV1 > 0.8L (or at least 40% of predicted), DLCO > 12, FVC > 1.5L
What is DLCO? Diffusing capacity of the Lung for Carbon Monoxide, based on pulmonary capillary surface area, hemoglobin content, and alveolar architecture
What preoperative ABG values prohibit lung resection? pCO2 > 45 or pO2 < 50 at rest
What has the strongest influence on survival of lung cancer? Nodal involvement
What are the two main types of non-small cell carcinoma? Adenocarcinoma (most common lung CA, usually more central) and squamous cell (more peripheral)
What paraneoplastic syndrome is most common with squamous cell lung CA? small cell lung CA? Squamous – PTH-related peptide, Small cell – ACTH, ADH
What anatomic landmarks are seen during a mediastinoscopy? Right – azygous and SVC; Left – RLN, esophagus, aorta, main PA; Anterior – innominate vein/artery, right PA
When should a mediastinoscopy be performed for lung CA? Suspicious adenopathy (>0.8cm or subcarinal >1.0cm) or centrally located tumors
What other cancer types benefit from isolated lung metastases resection? colon, renal cell, sarcoma, melanoma, ovarian, and endometrial CA
What appears as a popcorn lesion on chest CT? hamartoma – most common benign adult lung tumor
What are the common anterior mediastinal tumors? Thymoma (most common anterior mass in adults), thyroid Ca, parathyroid adenomas and goiters, T-cell lymphoma, Teratoma and other germ cell tumors (most common in kids)
What are the common middle mediastinal tumors? bronchogenic cysts, pericardial cysts, enteric cysts, lymphoma
What are the common posterior mediastinal tumors? Neurogenic tumors (most common overall), enteric cysts, lymphoma
What is the relationship between thymomas and myasthesnia gravis? 10% of MG have thymomas, but 90% respond to thymectomy
When do you resect a thymoma? All require resection, 50% are malignant
What are the 3 phases of an empyema? Exudative phase (1st week)-tx chest tube and abx; Fibroproliferative phase(2nd week)-tx chest tube and abx; Organized phase(3rd week)-fibrous peel around lung, likely need decortication
What lab values are associated with a chylothorax? pleural fluid with increased lymphocytes and TAG (>110), sudan red stains fat
What is the definition of massive hemoptysis? Treatment? >600cc/24hrs from high-pressure bronchial arteries. Place bleeding side down, main stem intubate opposite side, OR for lobectomy or pneumonectomy
When do you operate on a spontaneous pneumothorax? recurrence, large blebs on CT, air leak > 7 days, nonreexpansion, high risk profession (diver, pilot), or patients in remote areas
What is pulmonary sequestration? Treatment? mass of non-functioning primitive tissue in the lung. Extralobar - systemic artery and vein - resection not necessary. Intralobar (75%) - aorta in and pulmonary vein out - lobectomy for recurrent infections
Chest imaging shows a parenchymal lesion and enlarged hilar lymph nodes, what is the treatment? This is a ghon complex (tuberculosis) – INH, rifampin, pyrazinamide
What causes improved exercise tolerance and pulmonary function after lung reduction surgery? Increased elastic recoil
What do you suspect with a pansystolic murmur 2-7 days after an MI? Post-MI VSD
What is the treatment of aortic dissections? Ascending always needs surgery; descending gets medical management unless persistent pain or end-organ ischemia
What is the most common congenital heart defect? Ventricular septal defect
What is a catamenial pneumothorax? PTX occurring in temporal relation to menstruation, caused by endometrial implants in visceral lung pleura
Which congenital heart defects cause R –> L shunts? Cyanotic heart disease – tetralogy of fallot, transposition, and truncus arteriosus
What are indications to repair a VSD? CHF resulting in failure to thrive (most common reason), PVR>4-6 Woods units, or before shool age
What is the treatment for a patent ductus arteriosus? Indomethacin - blocks PG production - effective in ~70%
What is the restenosis rate after PTCA? 20-30% in <1 year
What is the best conduit for CABG? Internal mammary artery - >90% 10 year patency rate
What are indications for CABG? intractable symptoms, >50% left main, triple vessel disease, 70% LAD + 1 other vessel
Which patients should receive a tissue valve over mechanical valve? For patients who desire pregnancy, have contraindications to anticoagulation, are older, or are unlikely to need another valve in their lifetime
What are the cardinal symptoms of aortic stenosis? Angina – develops in 65%, mean survival 5 years; Syncope – 25% of patients, mean survival 3 years; Heart failure – mean survival 2 years (strongest prognostic indicator)
What vessels have the lowest oxygen tension? Coronary veins due to high oxygen extraction by myocardium
What are the symptoms of postpericardiotomy syndrome? Treatment? pericardial friction rub, fever, chest pain, SOB, diffuse ST elevation on EKG; tx: NSAIDS and steroids
What is the first sign of cardiac tamponade on echo? Decreased right atrial diastolic filling
What is idiopathic hypertrophic subaortic stenosis? marked hypertrophy of left ventricle and LV outflow tract, causing narrowing of LVOT during systole. Adequate volume is needed, as not enough afterload will cause aortic outflow tract to collapse, resulting in pulmonary edema
What is the key index of disease progression for mitral regurgitation? Ventricular function
What layer of the vascular wall is primarily effected by atherosclerosis? By Hypertension? Athersclerosis – intima, HTN – media
How do the internal and external carotid arteries communicate? Ophthalmic artery (first branch off ICA) and internal maxillary artery (off ECA)
What is a Hollenhorst plaque? Cholesterol embolus seen in a blood vessel of the retina, signifies atherosclerotic disease, usually of the ICA
When should you consider emergent CEA? Fluctuating neurologic symptoms, or crescendo/evolving TIAs
What is the initial treatment of claudication? smoking cessation, excercise, trental - not surgery
What is the most common CN injury during CEA? vagus nerve (clamp application) - hoarseness
What is the treatment of carotid traumatic inury with major fixed deficit? If occluded, do not repair (may exacerbate injury), if not occluded then repair
What is the most common site of a thoracic aortic transection? Tears at ligamentum arteriosum just distal to left subclavian (deceleration injury)
What are the classifications of aortic dissections? Stanford A – any ascending involvement, B – descending only; DeBakey I – Ascending and Descending, II – Ascending only, III – Descending only
What is the most common location of AAA rupture? Left posterolateral wall, 2-4 cm below renals
When do you reimplant IMA during a AAA repair? backpressure <40mmHg (poor backbleeding), previous colonic surgery, stenosis at SMA, or inadequate flow to left colon
Bloody diarrhea POD 2 after AAA repair - what is the next step? sigmoidoscopy to evaluate for ischemia (due to loss of IMA) - if necrosis then take to OR
What are the most common organisms in mycotic aneurysms? 1 – Salmonella, 2 – Staphylococcus
What are the types of endoleaks? Type 1 – leak at attachment sites, 2 – backbleeding from lumbars or IMA, 3 – graft on graft, 4 – Porosity. Need to fix/revise types 1 and 3
Describe the neurovascular structures in the lower leg compartments Anterior – deep peroneal nerve, anterior tibial atery; Lateral – superficial peroneal nerve; Deep posterior – tibial nerve, posterior tibial artery, peroneal artery; Superficial posterior – sural nerve
What is Leriche syndrome? Buttock or thigh claudication, impotence, and absent femoral pulses caused by lesion at aortic bifurcation or above
At what ABI do you start to get: Claudication? Rest pain? Ulcers? Gangrene? ABI < 0.9 = claudication, <0.6 = rest pain (usually across distal arch and foot), <0.5 = ulcers, <0.3 = gangrene
What abnormalities are seen after reperfusion of ischemic tissue? Lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome
What is a malperforans ulcer? Treatment? Chronic foot ulcer usually at metatarsal heads found in diabetics with neuropathy. Tx: nonweightbearing, debridement (need to remove cartilage), antibiotics, assess need for revascularization
What is the most common peripheral aneurysm? popliteal
What are popliteal aneurysms associated with? 50% bilateral, 1/3 have AAA
What is popliteal entrapment syndrome? Treatment? Medial deviation of popliteal artery around head of gastrocnemius muscle causing loss of pulses with platarflexion and intermittent claudication. Tx: Resection of medial head of gastrocnemius with possible arterial reconstruction
What are the success rates for BKA vs AKA? BKA – 80% heal, 70% walk again, 5% mortality; AKA – 90% heal, 30% walk again, 10% mortality
What are the signs/symptoms of acute arterial emboli in a limb? Pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis
What is the cause and treatment of “blue toe syndrome”? Flaking atherosclerotic emboli off abdominal aorta or branches, usually good distal pulses. Tx: may need aneurysm repair, endarterectomy, or arterial exclusion with bypass
What are the causes of renovascular hypertension? Atherosclerosis (2/3) – left side, proximal 1/3, men; Fibromuscular dysplasia (1/3) – right side, distal 1/3, women
What is the most common type of thoracic outlet syndrome? Neurogenic (95%) – ulnar nerve distribution (C8-T1) most common
What is the normal course of the subclavian artery and vein? Vein passes over 1st rib anterior to anterior scalene muscle, then behind clavicle, artery passes between anterior and middle scalenes
What is the treatment of thoracic outlet syndrome? Neurogenic – resection of cervical ribs, divide anterior and middle scalenes, +/- 1st rib resection; Arterial – cervical and 1st rib resection, divide anterior scalene, bypass graft; Venous – thrombolytics, anticoagulation (may eventually need surgery)
What are the watershed areas of the bowel? Splenic flexure (Griffith’s point) and Rectosigmoid area (Sudeck’s point)
What is the medical treatment for nonocclusive mesenteric ischemia? Volume resuscitation, glucagon, papaverine, nitrates, and increase cardiac output
What is median arcuate ligament syndrome? Treatment? Compression of celiac artery causing chronic pain, weight loss, diarrhea, and a bruit near epigastrium. Tx: transection of median arcuate ligament with possible arterial reconstruction
When do you repair a splenic artery aneurysm? Symptomatic, pregnant, or woman of childbearing age
What is the treatment for most visceral and peripheral aneurysms? Exclusion and bypass graft (splenic and proximal common hepatic can just be excluded secondary to good collaterals)
What diagnostic procedure is contraindicated in Ehler-Danlos syndrome? No angiograms – risk of laceration to vessel
What is the most common reason of failure of AV grafts for dialysis? venous obstruction secondary to intimal hyperplasia
What is the source of a PE after IVC filter? Ovarian veins, inferior vena cava superior to filter, or upper extremity
Created by: jclanton82