ABSITE Flashcards
Name the compartment of the lower extremity and their important structures
Contents of the anterior v posterior triangle (2)
carotid
spinal accessory
Right v left path for recurrent alryng n
under scv
under arch
MC head and neck cancer
SCC
what muscle is innervated by the sup laryng
cricothyroid
SCC HnN risk factors
etoh, tobacco, hpv
oral SCC over 4 cm gets
WLE + MRND ++ rads
most malign to least malign salivary gland
SL>SM> parotid
Mucoepidermoid significance and treatment
MC salivary gland tumor
Superficial parotidectomy w/ MRND +- chemorads
slow growing salivary tumor, what tx is it very sensitive to
adenoid cystic
XRT
MC benign salivary and tx
Pleomorphic
sup parotidectomy
warthin tumor tx?
watch
This nerve is often sacrificed during lower parotid pole dissection
greater auricular
numbness of ear
unknown head/neck node work up , 4 big things
PE
FNA
CT head/neck/chest
OR for direct laryngoscopy, egd , ipsi tonsil
no primary cancer identified after finding node head and neck, MC site
tx if nothing found
tonsil then bas of tongue
ipsi MRND and b/l XRT
margins for melanoma
1mm 1cm
2mm 2cm
size cutoff for melanoma SLNB
> .8 OR <.8mm with ulceration
ebv related hnN cancer
nasopharyngeal SCC
gustatory sweating after parotidectomy
n damaged?
Frey’s
auriculotemporal
swellign at angle fof jaw in elderly post op
bug?
supp parotiditis
S aureus
origins of sup thyroid a and inf thyroid a
ext carotid
thyrocervical trunk
consider what for re-op thyroids/invasive CA
laryngoscopy to assess recurrents
these cells make thyroglobulin
Which T is active for
m
follicular
T3`
lateral thyroid lobes derive from…
ventral 4th pharyng pouch
C cells develop from
4th and 5th pouches
thyroglossal duct cyst originates from…
foramen cecum, pyramidal lob
2 hyperthyroid meds and their shared side effects
PTU methimazole
PTU in preg
agran, aplastic
cretin in meth
Graves abs
TSH rec
when should RAI not be used for GRaves
optho
pre op med for hyper thyroid
Lugols – decreases vascularity
Hashimoto abs, PE for this process
anti-thyroid peroxidase
painless goiter
Painful goiter most likely..
tx?
subacute gran
viral
NSAIDS, steroids
hard non tender goiter
Riedel
Bethesda
parameters for thyroid lobectomy
4cm
how does follicular ca of thyroid spread
who is this more common in
Why is this different to dg than other thyroid
hem
women
need lobe to dg
tx for follicular
total, MRND for pos nodes, post op RAI
medullary thyroid oncogene
cell type
marker
RET
c cells
calcitonin
med thyr ca tx
total with central
when should MEN kids have thyroid out
5y
or 1y if highest risk
most common sites for the thyroid nerves
sup - sup pole
rec – ligament of berry
sup and inf PT gland origins
Thymus?
4th
3rd
3rd
blood supply to PT glands
inf thyroid
PTH is released by these cells
Chief
pth effect on bone and kidney
Stim osteoclasts for inc ca and phos
stim calcium resor and phos/bicarb inhibition
how does pth interact with vit D
Converts 25 VD to 1,25 VD via 1 a hydroxylase
From what organ and what cells is calcitonin secreted
kidney and bone effects
inhib ca and phos
inhibi osteoclasts
MCC of inpatient v outpatient hyperca
prim hyperpth
malign
most common causes of PTH overproduction due to malignancy
breast, squamous lung
bone
initial tx and secondary treatment of hyperca
NS at 300
lasix
MCC of primary hyperpth
adenoma
hyperplasia
PT CA
hyper pth cl to phosratio
normal pth level
> 33
5-40
re-op imaging for PTH gradients
angiography with venous sampling
6 reasons for asymptomatic hyperparathyroid surgery
inc Ca by one
renal issues
osteo T<-2.5
stones
poor follow up
under age of 50
tx of secondary hyperpth
ca suppl, phosphate binders, renal diet
mng of tertiary hyperpth
4 gland pthectomy
op for pth cancer
enbloc
ipsi thyroid
+- ipsi neck disseciton
high pth and ca, low urine calcium
benign familial hypocalciuric hypercalcemia
ectopic superior pth gland
RE space or carotid
surgery for hyperpth in MEN 1 or 2a
4 gland with thymectomy
ectopic pth inferio glands
thymus, intra-thyroid
blood supply to esoph
inf thyr
aorta
L gastric and inf phrenic
upper sphincter muscle and innervation
cricopharyngeus
recurrent laryngeal
superior laryngeal n innervates…
cricothyroid
where is killians triangle and why is it improtant
superior to crico pharyng and inf to contrictors
site of Zenkers
MC sites of iatro and non iatro esoph perfs
cricopharyng
distal esoph
study of choice for esoph perf
swallow, esophagram
which contrast should be used first in esoph perf swallow eval?
gastrograffin,
barium if negative
3 antibiotic regimen for perf esoph
unasyn, metro, fluc, ceftri
achalasia manometry
inc relax les with aperistalsis
how long should heller myotomy be
cm on esoph2 cm on stomach
describe operation for perforated achalsia
contralateral heller with primary repair
hypertensive les med
CCB
DES meds
ccb, nitrates
where are the 2 pulsion divert in esoph
zenekers and epiphrenic
where is the esoph traction divert?
mid thoracic
what is the cellular change in barretts
why does this occur
how much does this inc cancer risk
squam to columnar
acid
30-60X
surveillane for no dysplasia barrets
2 year then q 3
4 quad bx q2cm
Low grade barrets follow up time
6 m
High grade barrets recs
EMR
MC benign esoph tumor
Tx?
leiomyomas
enuc
esoph cancer risks for each
scc: tobacco and alcohol
adeno: gerd, obes, barretts
staging for hyroid cacncer
stage 1 and 2 younger than 45
over 45 has all stages
esoph ca TNM
what stage gets preadj for esoph ca
t2
criteria for low risk esoph t1a and what tx can low risk get
2 cm, mod-well diff, no LN
ERM
which surgery for distal esoph tumor
what arteries are preserved
ivor lewis, right thoracotmy and laparotomy
R gastroepiploic and R gastric
what chemo regimens are available for esoph ca
CAPOX and FOLFOX
dysphagia + thickened palms
risk of …
Fist egd when
tylosis
SCC
20y
shatzki ring tx
dilation
low urine calcium level
less than 100
5 risks for gastric stress ulcers
Prolonged vent
Coag
Head
Burns
PUD hx
percent of h pylori in gastric v duo ulcers
75%
95%
risk of rebleeding
arterial
visible
adherent clot
clean
80
50
20
5
gastric polyp size cutoff for biopsy
.5cm
MC mesenchymal tumor of the GI tract
cell of origin
GIST
int cells of cajal
appearance of cells for GIST
definitely will see this marker
maybe these 4
spindle,epithelioid
ckit(CD117)
CD34, DOG-1, desmin vimentin
Stage 1 A v Stage 3B for GIST
<5cm low mit
> 10 cm high mit
How do GIST metast
hematogenously
bad spots for gist
esoph, colon,l rectum
adjuvant treatment for gist(alternative if no ckit)
surgical resection type
imatinib
sunitinib
en bloc to neg margins
mechanism of imatinib
tyr kin inhib
intest vs diffuse gastric cancer pertaining to mode of mets and diff
hematog, well
lymph, poorly
Hereditary diffuse gastric cancer marker
CDH1
general recommendations for CDH1 carriers
gastrectomy 18 to 40y
high risk screening for women for Breast ca
4 syndromes with inc gastric ca risk
Lynch (dna mismatch)
JPS(SMAD4)
PJS
FAP(APC)
what is recommended for all T2 gastric tumors
dg lapwith washings
tnm for gastric ca
who gets preadj for gastric cancer
Regimen?
T2
FOLFOX
general resection principles with gastric ca
distal specific
6cm margins, 16 LNs
2cm distal
diff between D1 and D2
stomach nodes
Celiac plexus
when is adj chemo rec for gastric cancer
Regimen
T3 or nodal
5FU based
What are the primary cells of the antrum
body and fundus
G cells
parietal cells
mech of early vs late dumping
hyperosmolar load
insulin surge
mechanism and secondary effects of afferent limb syndrome
bacterial overgrowth
steatorrhea, malnutrition, B12 def
gastric bx of sheets of neoplastic small lymph cells
tx?
MALToma
h pylori tx
5 non trauma splenectomy indications
ITP, sphero, splenic abscess sympt cyst, non hodgkins lymphoma
mech of itp
Initial management
Gii/giiia abs
steroids and IVIG
when and at what time do you give intraop plt for ITP
if bleeding occurs
after artery ligated
hereditary spherocytosis recs
splenectomy after 6y of age along with chole if needed
splenic abscess is caused by …(4)
IV drugs, endocard, 2nd inf to trauma pseudo, SCD
2 types of splenic abscesses and their treatments
simple: perc
multiloc: splen
diff cyst from abscess for spleen
wall enhancement for abscess
cyst work up and treatment parameters
serology to rule out echinoccocal
take out if sympt or greater than 5cm
risk factors for angiosarcma spleen
vinyl chloride, thorium dioxide
MC splenic tumor
tx?
hemangioma
resect if sympt
splenic artery aneurysm tx parameters
Tx
> 3cm and all pregnant or women of child bearing age(70% rupture during pregnancy)
coil
MC OPSI bug
S pneumo
treatment of wandering spleen
pexy if no infarction, splenectomy otherwise
fever, hemo anemia, renal failure, purpura, neuro
mech
tx
TTP
ADAMS vWF cleaver
plasmapheresis
ipiliminab is used in ….
mech
melanoma
anti CTLA4 promotes T cells
Nivolumab used in ….
mech
melanoma, lympoma, colon, gastric, head, liver
anti PDL-1:removes checkpoint inhib
chemo man
Genes involved in Lynch/HNCCS
MSH2, MLH1, MSH6, PMS2
mismatch repair genes
What cancers are affected by mismatch repair genes
colon, endo, gastric, SB, panc, GU, ovarian
screening for lynch
colon at 20
EGD at 30
endom vac at 25
Muir torre syndrome?
Sebacious cysts Plu colon/GU cancer
Fap gene, mech
APC
tumor suppressor gene beta catenin
FAP screening
egd 20
colon 12
thyroid 20
Turcot syndroms
FAP or HNPCC + brain tumor
Lifraumini gene
cancers
recs
TP53
breast, gastric, sarcomas, leukemia
annual WB MRI plus brain
double scopes at 25
what type of genes are BRCA
4 cancer risks
Screening recs
TSG
breast, ovarian, melanoma, panc ca
MRI at 25; men annual exams
CDH1 mutation
ca
recommendations
e cadherin
egd at 20 for gastric
consider ppx gast, possible mastetomy
PJS gene and type
ALLLLL the cancers
screening
STK11, TSG
hamartomas, hyper pgi, gastric polyps, breast, ovarian, fallopian, cervical, thyroid, lung, panc, testis
all scopes at 8, PILL
Post colectomy screening after colectomy for …..
EGD for duo ca
What phase is most vulnerable to rads
M phase
CEA assoc cancer
colon
19-9
panc and hpb
ca 125
ovarian
AFP
HCC, non seminomas
LDH
melanoma, testis
Her2
breast and esoph
Chromogranin
Carcinoid
Carotid sheath anatomy
carotid sheath nerves
What vessel usually overlies the carotid bifurcation
facial vein
first branch of the ext carotid
superior thyroid a
what is the doppler flow on the ext carotid
triphasic, brief reversal (high resistance
What nerves are encountered in order moving up past the bifurcaition
1st and second arteries off the ext carotid
Specific muscle encountered
Describe int carotid flow
long coninuous low res diastolic phase
First branch of int carotid
opthalmic
hoarseness after carotid
vagus clamp
tongue toward the cea side???
hypoglossal injury
ipsilateral mouth droop after cea
MMA
what layers are removed in CEA
disabling dysphagia after?
intima and part of media
glossopharyngeal
CEA indications symp v asym
50%
70% or EDV >140 and healthy
mng of CS symptomatic <50%
dual anti plt, statin
MCC of mortality CEA
MI
Important pre CEA workup
Cardiac
recent stroke, when to do CEA
2 wks
6wks(hem)
headache and htn post cea, normal neuro
Tx
cerebral hyprperfusion htn
Htn control emergently, s eizure ppx. CT
PACU CEA stroke symptoms, next steps and 2 pathways
Doppler
Patent ICA –> CT or on table angio
Thrombus–> OR
symptomatic BCVI mng
anticoag
then stent
Carotid body tumor mng
dont bx!
resect
bead of string appearance of renal or carotid and tx
fibromusculay dysplasia
aintiplt
ballon if recurrent
Thoracic outlet order
MC form of thoracic outlet syndrome
neurogenic
what anomoly sets you at risk For TOS
cervical rib
borders of brachial plexus
artery ant
mid scal post
Nerve disribution in hand
s/s of TOS
Ulnar distribution
first step for neurogenic TOS
PT
then surgery
Swimmer with blue arm
paget schroetter, SV thrombosis
thrombolysis with first rib resection same hospitalization
describe subclavian steal
fistula rules:
what 2 veins and what size cutoff
what size and characteristics for artery? why?
cephalic and basillic, 3mm
2mm, triphasic to prevent steal
why is the issue usually the vein with fistulas
high pressures scar down veins
bleeding fistula with high venous return pressures
venous stenosis on duplex
fistula gram with angioplasty
rules for fistula formation
6mm diam
6mm deep(not tooooo deep)
> 600ml/min flow
3 reasons for non-maturing fistula
- anastomotic stricture
- side branches
3 venous outflow
dg for steal in hand
50% improvement in waveform analysis with compression
mng of steal(2)
mng of occasional mild s/s
DRIL or ligation
obs
Lateral fasc nerve injury
superficial peroneal with diffiulty in foot eversion
