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ABIM - Random

Surgery Case Files 1

QuestionAnswer
Inheritance pattern of malignant hyperthermia autosomal dominant
rapid rise in temp (up to 40C) upon induction of anesthesia Malignancy Hyperthermia
What anesthetic agents associated with malignant hyperthermia? succinylcholine, inhaled halogens
What is the best treatment for malignant hyperthermia? Prevention
Steps of clinical problem solving 1. make the diagnosis, 2. establish severity, 3. tailoring the treatment to stage of disease, 4. monitor tx response/efficacy
Most common cause of serosanguinous unilateral breast dc? Intraductal papilloma
"Intraductal papilloma small, noncancerous (benign) tumor that
grows in a milk duct of the breast"
What is the main concern in a pt with serosanguinous unilateral breast dc? breast cancer
How can you r/o intraductal papilloma on physical exam? Palpate for involvement of more than one breast duct. If more than one involved, or a breast mass is palpated, most likely breast cancer.
Most common cause of serosanguinous unilateral breast dc in the presence of a breast mass? breast cancer
33 yo woman w 3cm palpable L brst masa; L axilla and R breast are nl; what to do next? tissue bx; if malignancy, then stage which would inc BL mammography
33 yo woman w 3cm palpable L brst masa; L axilla and R breast are nl; if breast CA, how to tx? If CA, most likely stage Iia --> best managed by 1. surg, 2. adjuvant therapy OR NEOADJUVANT: 1. systemic chemo to shrink tumor, 2. locoregional surgical therapy
What is adjuvant therapy? Chemo or radiation AFTER surgery.
What is neoadjuvant therapy? Treatment given as a first step to shrink a tumor before the main treatment, which is usually surgery, is given. Examples of neoadjuvant therapy include chemotherapy, radiation therapy, and hormone therapy. It is a type of induction therapy.
Metastatic w/u for br ca CBC, LFT's, CXR
What should a pt with breast ca get before consideration of breast conservation therapy? Breast MRI to help delineate the local extent of ca
Br Ca TNM Staging Stage 0 Tis (in situ), N0, M0
Br Ca TNM Staging Stage 1 T1 =<2cm , N0, M0
Br Ca TNM Staging Stage 2A T0-1, N1, M0; T2, N0, M0
Br Ca TNM Staging Stage 2B T2, N1, M0; T3, N0, M0
Br Ca TNM Staging Stage 3A T0-T2, N2, M0; T3, N1-N2, M0
Br Ca TNM Staging Stage 3B T4, N0-2, M0; Tany, N3, M0
Br Ca TNM Staging Stage 4 Tany, Nany, M1 (distant mets)
Br Ca TNM Staging T1 T1 =<2cm
Br Ca TNM Staging T1a T1a =<0.5cm
Br Ca TNM Staging T1b 0.5cm < T1b =< 1cm
Br Ca TNM Staging T1c 1cm < T1b =< 2cm
Br Ca TNM Staging T2 2cm < T2 =< 5cm
Br Ca TNM Staging T3 T3 >5cm
Br Ca TNM Staging T4 T4 - extension to chest wall or skin
Br Ca TNM Staging T4a T4a - extension to chest wall
Br Ca TNM Staging T4b Edema or ulceration of the skin
Br Ca TNM Staging T4c extension to chest wall + skin
Br Ca TNM Staging T4d inflammatory carcinoma
What is inflammatory breast carcinoma? rare but very aggressive type of brCA in which the cancer cells block the lymph vessels in the skin of the breast. “inflammatory” because the breast often looks swollen and red, or “inflamed.” diagnosed at younger age
Br Ca TNM Staging N0 no regional nodal mets
Br Ca TNM Staging N1 mobile ipsilateral axillary nodal mets
Br Ca TNM Staging N2 fixed ipsilateral axillary nodal mets
Br Ca TNM Staging N3 ipsilateral internal mammary nodal mets
What is the limitation of FNA of a breast mass? What would be better and why? identify CA cells but cannot differentiate invasive CA from in situ; need core needle bx to determine the histology of tumor and assess receptor status and tumor biology of the cancer
Breast conservation therapy partial mastectomy with axillary staging by sentinel LN bx or axillary dissection. Usually, radiation to chest wall after surgery to decreased local recurrance.
Triple Receptor Negative BrCa; what are the receptors? Slow vs. aggressive? What demographic? Prognosis? Percentage of all BrCa. no estrogen/progesterone/HER2-neu receptors; aggressive, more in AA and premenopausal; poor prognosis; 10-15% of all BrCA's
Three steps in management of BrCa 1. Diagnosis, 2. Locoregional therapy, 3. Systemic therapy
How do you diagnose Br Ca? Hx, exam, imaging, bx
What imaging is used for diagnosis of BrCA? US/Mammography, MRI in some
What kind of bx's done for BrCA? (3) FNA, core needle bx, excisional
If stage I or stage II tumor (T1-2), what 3 things to stage? CBC, LFT's, CXR
If BrCA + bone pain and/or abdominal sx's and/or HA or neuro complaints, what should staging be done with? CBC, LFT's, CXR + bone scan, abd CT, brain CT or MRI, depending on sx's (common: full body PET plus MRI brain)
With proper pt f/u, which offers greater survival benefits? BCT or mastectomy? they offer equivalent survival benefits
Which technique for nodal staging is preferred? Axillary LN dissection (levels 1 and 2 - lateral and deep to the pec muscles) vs. sentinel LN bx SLNBx because it provides satisfactory staging and produces less morbidity. However, when SLN is + for metastases, a complete dissection of Level 1 and 2 axilla is performed
Systemic therapy given to what stages in BrCA? those at risk of mets - stages 3 and 4
What are the options for pt in stages 3 or 4 BrCA? surgery followed by chemo or neoadjuvant chemo followed by surg
BrCA pts with stage 2 disease - what is the risk of recurrance at 20 y if pt got locoregional tx only? 33 to 44%
BrCA pts with stage 2 or greater are offered what kind of therapy and why? systemic chemo in addition to locoregional control, with radiation therapy for breast conserving surgery
which is associated with improved survival? Neoadjuvant or adjuvant therapy? no survival difference between the two; advantage of neoadjuvant theraly includes improvements in breast conservation rate --> improved cosmetic results
Tamoxifen associated with development of what? given to tx BrCa recurrence, but develop uterine CA
Who are good candidates for aromatase inhibitors? postmenopausal women who have BrCA with estrogen-receptor-positive tumors
What is locoregional tx for brCa Surgery and radiation therapy
What is systemic tx for BrCA chemo, anti-estrogen therapy
Mechanisms contributing to GERD (5) 1. dec LES fxn, 2. impaired esophageal clearance, 3. excess gastric acidity, 4. dec gastric emptying, 5. abnl esophageal barriers to acid exposure
Complications associated with GERD (3) 1. peptic stricture, 2. Barrett esophagus, 3. extraesophageal complications
peptic stricture narrowing of the esophagus (usu due to damage of esophageal lining)
Barrett's esophagus; what is it? Increased risk for what? chronic acid to lower end of esophagus --> esophageal damage --> metaplasia of squamous epithelium to columnar epithelium (intestinal-type lining) --> inc risk for esophageal adenoCA
hoarseness and wheezing in AM in someone with GERD pharyngeal reflux with silent aspiration, r/o oropharyngeal and vocal cord pathology (see ENT)
PPI produces relief of sx's in what percent of population with GERD? 0.95
How to diagnose GERD? Endoscopy, 24h pharyngeal pH monitoring (supports silent aspiration -- how?)
Extraesophageal complications of GERD (4) laryngitis, reactive airway dz, recurrent pna, pulmonary fibrosis
describe the pressure around the LES LES serves as a zone of increased P between the positive pressure in stomach and the negative pressure in chest;
Who should get worked up for GERD? Self-limiting or mild sx's do not require w/u. Those who do need it: 1. longstanding sx's, 2. atypical sx's (wheezing, cough, or hoarseness), 3. recurrance after cessation of medical therapy, 4. unrelieved sx's while on max dose PPI's
If pt is to undergo surgical anti-reflux procedure, what is the standard w/u? 1. endoscopy, 2. manometry, 3. 24h pH probe testing, 4. barium esophagography
What is the purpose of endoscopy in GERD w/u? evaluates for erosive esophagitis or Barrett esophagus or alternative pathology. Bx for suspected dysplasia or malignancy.
What is the purpose of barium esophogram in GERD w/u? 1. ID location of GE junction in relation to diaphragm, 2. ID hiatal hernia, 3. ID shortened esophagus, 4. eval gastric outlet obstruction, 5. can demonstrate spontaneous reflux.
When is a fundoplication contraindicated in GERD pts? 1. in gastric outlet obstruction (seen on barium esophagogram), 2. aperistalsis (see on manometry)
What is the purpose of 24h pH monitoring in GERD pt? Correlates sx's with episodes of reflux. Also quantifies reflux severity.
What is the purpose of pharyngeal pH monitoring in GERD pt? Correlates respiratory sx's with abnl pharyngeal acid exposure
What can manometry evaluate in GERD pt? 1. competency of LES, 2. adequacy of periostalsis prior to planned antireflux surg, 3. ddx motility d/o such as achalasia or diffuse esopahgeal spasm
If pH monitoring in pt being evaluated for GERD cannot be performed, what can be done instead? Nuclear scintigraphy - evaluates reflux and gastric emptying
What is initial tx for pt with GERD sx's? behavioral therapy and PRN meds
For pts with esophagitis or frequent GERD sx's, what is the tx? PPI's - acid suppression
When is surgery indicated in pt with GERD? 1. documented GERD with persistent sx's despite max PPI dosing, 2. can't tolerate PPI's, 3. don't want to take lifelong meds
What surgery is done to tx severe GERD? laproscopic Nissen fundoplication - 360-degree wrap of fundus of the stomach around the GE jxn to create a valve effect.
What is the longterm success with antireflux surgery (lap Nissen)? 0.9
What are lifestyle changes pts can make to tx GERD? 1. foods - avoid caffeine, EtOH, high fat, 2. avoid meals 2-3 h before bedtime, 3. elevate head while sleeping/lying down, 4. if obese --> wt loss, 5. smoking cessation
What groups of meds can you give GERD pts? 1. PPI, 2. H2-antag, 3. antacids, 4. prokinetic agents
pt with GERD on H2 blocker becomes symptomatic and is found to have Barrett's esophagus on endoscopy - what do you do next? start PPI and do interval endoscopic surveillance of the Barrett's
for GERD, when should diagnostic endoscopy be performed? When pts have longstanding GERD and when sx's are refractory to meds
what has better long term efficacy for reducing development of esophageal cancer in GERD pts - PPI or surgery? they are equivalent
longstanding GERD increases risk of what CA? esophageal adenoCA
what is one of the most reliable clinical indicators that a person has GERD? relief of sx's with PPI
What is the most reliable objective indicator of GERD? 24hr pH monitoring
Boerhaave Syndrome Spontaneous esophageal rupture
Is esophageal perforation a surgical emergency? Yes
Spontaneous esophageal performation comprises what percentage of all causes of esophageal perforation? 15%; most of the time, esophageal perforations are iatrogenic from a procedure
Acute onset of CP after vomitting typical of Boerhaave Syndrome
Sx's of Boerhaave Syndrome Acute onset of CP after vomiting, shoulder pain, dyspnea, midepigastric pain; pleural effusion (75%)
Signs of systemic infection tachycardia, fever, leukocytosis
Most spontaneous esophageal ruptures occur in the distal third of esophagus about GR jxn. What side pleural effusion more common? L
In esophageal perforation - what is the timeline of CP? immediate and persistent; most common presenting sx
In esophageal perforation - what is the timing of subQ emphysema? 1h after perforation - may not be present wth lower esophageal perforation
In esophageal perforation - what is the timing of pleural effusion? Can be immediate or after 6h; happens in 75% of cases; mostly on L
In esophageal perforation - when would you see fever and leukocytosis? What would it be from? >4h from sepsis from mediastinitis
In esophageal perforation - what is the chance of death? If dx <24h, 15%; if dx > 24h, >40%
In esophageal perforation - what is the best initial diagnostic test? Water soluble contrast esophagogram - ID in 90% of cases
In esophageal perforation - What position should pt be in when getting esophagogram? R lateral decubitus
What is the most common presenting sx of esophageal rupture? CP
subcutaneous emphysema air is present in the subcutaneous layer of the skin; characteristic crackling feel to the touch, like Rice Krispies;[2] crepitus.
Initial tx of esophageal perforation ABC's, IVF, abx, chest tube
Tx principles for spontaneous esophageal perforation 1. surgical drainage, 2. debridement, 3. repair, 4. diversion
What kind of surgery is done for spontaneous esophageal perforation? chest thoracotomy (R posterolateral) --> exposure of tear, debridement, primary suture repair, reinforcement (with flap), drainage
What is the follow up for spontaneous esophageal perforation? restudy with esophagogram in 1 week for presence of leak
achalasia esophageal motility disorder: smooth muscle layer of the esophagus loses normal peristalsis and the LES fails to relax properly in response to swallowing. Characterized by difficulty swallowing, regurgitation, and sometimes chest pain
pt w CP after vomiting, subQ emphysema on exam, and Lsided pleural effusion spontaneous esophageal perforation
Where do most spontaneous esophageal ruptures occur? Distal third of esophagus
How to evaluate pigmented skin lesions? ABCDE: Asymmetry, Border irreg, Color change, Diameter increase, Enlargement or elevation
What is malignant melanoma? CA of the pigmented cells of the skin (melanocytes)
What factors used to stage malignant melanoma? Depth of invasion, ulceration, LN status
Where on the body is malignant melanoma most likely to occur? Evenly distributed among head, neck, trunk, and upper and lower extremities
Genetic risk factors for development of malignant melanoma, in decreasing order prior hx, fam hx, white, easily burn/unable to tan, blue eyes, >20 nevi on body, red hair, fair skin
Environmental risk factors for development of malignant melanoma Sunlight (esp UVB), near equator, 1st sunburn at young age
Other risk factors for development of malignant melanoma (not genetic, not environmental) tanning lamps, UVA exposure, higher SES, immunosuppression, halogenated compounds, alcohol/tobacco, coffee/tea
Name the 4 types of melanoma 1. superficial spreading, 2. nodular sclerosis, 3. lentigo maligna, 4. acral lentiginous
What is the most common type of melanoma? superficial spreading (70% of cases)
Malignant melanoma - superficial spreading female predominance, prolonged radial growth phase (1 to 10 y), late vertical growth phase, good prognosis
Malignant melanoma - nodular sclerosis second most common, 15-30%, aggressive vertical growth phase, poor prognosis
Malignant melanoma - lentigo maligna 4-10%, long radial growth phase (5-15 y), good prognosis
Malignant melanoma - acral lentiginous 35-60% in AA, Asian, Hispanic; primarily on palms and soles and in nail beds; aggressive vertical growth phase, poor prognosis
5y survival for stage I melanoma with thickness of <0.75mm >96%
which is more accurate prognostic indicator - depth of invasion or level of invasion? Depth (Breslow) - overall 5y survival correlates with tumor thickness
How does ulceration of lesion affect cancer staging? stage is increased
Minimum surgical margin width for 1. melanoma in situ, 2. <1.5mm tickness, 3. 1.5-4mm, 4. >4mm 0.5cm, 1 cm, 2 cm, at least 2 cm
for pts with malignant melanoma, what is the tx if they have palpable adenopathy? complete lymphadenectomy of the involved LN basin
which malignant melanoma pts would benefit from prophylactic LN dissection? intermediate depth - 0.75mm to 4mm; prophylactic LN dissection in this population associated with longer survival
Is adjuvant therapy recommended for melanoma? Minimal benefits for stage I and II, limited for stage III
prognosis for stage 4 melanoma 6 to 9 mo
tx for stage 4 melanoma high-dose IL2 (9% durable response, 8% partial response)
Created by: christinapham