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Surgery > Chapter 16 > Flashcards

Chapter 16 Flashcards

1
Q

What is the 5th most common cancer type?

A

Melanoma

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2
Q

What is the most common cause of melanoma?

A

BRAF mutation (60% of melanomas)

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3
Q

Age of melanoma

A

Wide range, often in women 20-30 yrs

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4
Q

Race predilection of melanoma

A

White 30x more likely

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5
Q

Hx of melanoma lesion

A

Recently developed or changing OR

FHx of CDKN2A or CDK4

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6
Q

Environmental factors of melanoma

A

UV radiation

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7
Q

Presentation of melanoma

A 
Asymmetry
Irregular borders
Color
Diameter >6 mm
Elevated surface
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8
Q

What is the most suspicious melanoma?

A

Superficial spreading > nodular melanoma > lentigo maligna > acral lentiginous

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9
Q

What is the MC noncutaneous melanoma?

A

Ocular melanoma

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10
Q

What is associated with a worse prognosis in pts with disseminated melanoma?

A

Elevated LDH

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11
Q

What type of margins should be achieved with less than or equal to 1 mm thickness melanoma?

A

1 cm margin

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12
Q

What type of margins should be achieved with 1-2 mm thickness melanoma?

A

1-2 cm

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13
Q

What type of margins should be achieved with >2 cm thickness melanoma?

A

2 cm

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14
Q

What is the MC site for the first metastasis of melanoma?

A

Regional LNs

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15
Q

What is now the standard procedure for detecting subclinical metastatic to the regional nodes?

A

Sentinel LN bx

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16
Q

When is surgical resection recommended for melanoma?

A

Pts with primary tumors >1 mm, with tumor thickness of 0.76 to 1 mm who have T1b lesions, and tumor thickness of 0.76 to 1 mm who have T1a lesions

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17
Q

When is resection not recommended in melanoma?

A

Pt with tumor thickness <0.76 mm

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18
Q

What high-risk features are rare in thin lesions but when present may warrant sentinel LN bx in selected individuals in whom it is not otherwise recommended? (melanoma)

A 
High mitotic rate
Lymphovascular invasion
Microsatellites
Clark level IV
Ulceration
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19
Q

What is the single strongest prognostic factor for pts with clinically localized melanoma?

A

The status of the sentinel node

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20
Q

How is a melanoma lesion identified?

A

Tech-99m labeled sulfur colloid
-Accuracy of the procedure is maximized by the additional intraoperative injection of isosulfan blue dye into the tumor site, which allows both visualization of the blue sentinel node and detection with a handheld gamma probe

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21
Q

What is recommended in stage II melanoma, in the absence of distant metastases

A

Therapeutic lymph node dissection

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22
Q

What is located in the inguinal region?

A

The superficial femoral nodes, which reside in the triangle between the sartorius muscle laterally; the adductor muscles medially; and the inguinal ligament superiorly

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23
Q

Where do the parotid, submandibular, submental, jugular, and posterior triangle lymph nodes drain?

A

Anterior to the ear and superior to the mouth

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24
Q

Where do anterior lesions inferior to the mouth drain?

A

To cervical nodes

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25
Q

Where do posterior lesions drain?

A

To occipital, postauricular, posterior triangle, and jugular nodes

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26
Q

What are complications of lymph node dissection?

A

Infection
Wound dehiscence
Seroma
Lymphedema

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27
Q

Who is at a high risk for local recurrence despite therapeutic lymph node dissection?

A

Pts with lymph node metastases that grow through the capsule of the lymph node (extracapsular extension) and those with extensive tumor burden in multiple nodes
-Consider adjuvant radiation therapy

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28
Q

In-transit metastases- lymphatic

A

Tumor deposits along the path of lymphatic drainage from the primary tumor to the regional lymph node basin

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29
Q

Prognosis of in-transit metastases- lymphatic

A

Worsens with increasing number

30
Q

Tx of in-transit metastases- lymphatic

A

Excision and sentinel lymph node bx or dissection

Additionally, isolate limb perfusion (ILP) and isolated limb infusion (ILI) have also been used

31
Q

Local recurrence of advanced lymphatic metastases

A

Regrowth of tumor within 5 cm of the primary resection site
4% rate of recurrence
Occurs more frequently in pts with thick (>4 mm) primary lesions and ulcerated tumors and in lesions of the foot, hand, scalp, and face

32
Q

Distant metastases lymphatic

A

To the lung, liver, brain, and bone are most common

33
Q

Tx options for distant lymphatic metastases

A

Observation- often warranted for asymptomatic pts in poor medical condition
Surgical resection of metastases- resection can provide effective palliation and a 5-yr survival of up to 29%
Radiation therapy- Palliative tx for symptomatic lesions and brain metastases
Chemo- combo regimens include dacarbazine are used predominantly but are now reserved for pts failing other options

34
Q

Target therapy for distant metastases- lymphatic

A 
BRAF inhibitors (vemurafenib, dafrafenib) target the activating mutation in BRAF (present in 60% of melanomas). Response rates of 50% but resistance develops after a median of 9 mos
MEK inhibitor (trametinib) often in combo with BRAF inhibition
35
Q

Biologic therapy for distant metastases- lymphatic

A

IL-2 results in 10-20% response rate (some responses are dramatic) but largely supplanted by ipilimumab
Anti-CTLA-4 antibody (ipilimumab) is associated with modest response rates but substantially improves overall survival
Anti-PD-1 antibody (pembrolizumab) recently demonstrated improved response rates and overall survival compared to ipilimunab in a phase II trial

36
Q

Soft tissue sarcoma

A

Malignant tumors of the mesenchymal origin (fat, muscle, connective tissue)
Most occur on the LEs and retroperitoneum is 2nd MC

37
Q

Genetic syndromes associated with soft tissue sarcoma

A

Gardner syndrome
Retinoblastoma
Neurofibromatosis I

38
Q

Types of soft tissue sarcoma

A

Leiomyosarcoma MC

Rhabdomyosarcoma (MC childhood sarcoma)

39
Q

What is the mainstay of therapy for soft tissue sarcoma?

A

Surgical resection

40
Q

What is the prognosis of retroperitoneal sarcoma?

A

15%, poor prognosis

41
Q

GIST

A

GI stromal tumor, rare, from interstitial cells of Cajal, receptor KIT (CD117), surgical resection is the mainstay of therapy if localized

42
Q

What percentage of lymphomas does Hodgkin lymphoma constitute?

A

10%

43
Q

Characteristics of Hodgkin lymphoma

A

A malignancy of B cells and can be characterized pathologically by the presence of Reed-Sternberg cells
Bimodal age distribution with first peak at ~20 yoa and a second peak at age 65

44
Q

What is the most common presentation of Hodgkin lymphoma?

A

Painless LAD

45
Q

What are the most commonly involved sites in Hodgkin lymphoma?

A

Cervical/supraclavicular lymph node basins followed by the axillary and inguinal node basins

46
Q

Alternate presentation of Hodgkin lymphoma

A

Incidentally discovered mass on imaging- most commonly a mediastinal mass with retroperitoneal adenopathy seen less frequently

47
Q

Other sx in Hodgkin lymphoma

A

Fever >38 degrees Celsius
Night sweats
Wt loss of more than 10% body weight over a 6-mo period
AKA B sx

48
Q

What does an eval of pts referred for lymph node bx for Hodgkin lymphoma include?

A

PE with detailed evaluation of all accessible lymphatic tissue
-Palpation of all superficial lymph node basins and abdominal palpation for hepatic or splenic enlargement

49
Q

Diagnostic laboratory studies for Hodgkin lymphoma

A

CBC with diff

Peripheral blood smear

50
Q

What is staging in Hodgkin lymphoma based on?

A

The extent of disease and the present or absence of B sx

51
Q

Staging workup for Hodgkin lymphoma

A

Liver function
LDH
ESR
CXR
CT scan (typically neck, chest, abdomen, and pelvis)
PET scan
Bone marrow bx recommended for stage IB, IIB and III-IV

52
Q

What is the tx modality of choice Hodgkin lymphoma?

A

Chemoradiation for all pts with stage I-II

Chemo , with or without radiation for more advanced stages

53
Q

Presentation of NHL

A

Can vary widely from an indolent course over yrs to an acute presentation that can be fatal within wks

54
Q

How are NHL tumors classified?

A

By their cell of origin (B cell, T cell, or rarely NK cells) with most cases of B-cell descent (80%)

55
Q

Presentation of NHL

A

More than 2/3 of pts with NHL present with LAD

56
Q

What is the surgeon’s role in NHL?

A

Obtain tissue for dx

Treat extranodal lymphomas in the GI tract

57
Q

What is one of the few indications for urgent performance of a LN bx in NHL?

A

Suspicion of an aggressive NHL lymphoma

58
Q

Gastric MALT

A

A clonal B-cell neoplasm typically associated with an indolent course but prone to local recurrence and occasionally capable of distant metastatic spread or degeneration into a high-grade B-cell lymphoma

59
Q

What is MALT lymphoma classically associated with?

A

H. pylori present in >90% of cases

60
Q

Tx of MALT lymphoma

A

For early dz, tx of H. pylori alone serves as a highly effective tx
For those with advanced dz or in whom H. pylori therapy fails, radiation therapy is typically highly effective with surgical resection reserved for cases in which radiation is contraindicated

61
Q

What is the MC site of involvement for extranodal NHL?

A

GI tract

62
Q

From where do the majority of GI lymphomas arise?

A

In the stomach (75%)

63
Q

Presentation of gastric lymphomas

A 
Abd pain
Wt loss
N/V
Bleeding
Rarely, perforation
64
Q

Tx for gastric lymphoma

A

Surgical resection is rarely employed
Chemo is the therapy of choice
Surgery is now reserved for those rare pts who develop complications from the dz or during therapy

65
Q

What are uncommon in the US but are the most common extranodal lymphoma in the Middle East?

A

Lymphomas of the small bowel

66
Q

When are there higher incidences of small bowel lymphomas?

A

In pts with celiac dz

67
Q

Where are lymphomas of the small bowel most often found?

A

Proximal jejunum

68
Q

Presentation of small bowel lymphomas

A

Obstruction
Intussusception
Bleeding

69
Q

Tx of small bowel lymphomas

A

Chemo is the mainstay
However, resection needs to be done to obtain a dx
Then, adjuvant chemo

70
Q

What are the MC noncarcinomatous tumors of the large bowel?

A

Colonic lymphomas

Surgery (30 decks)

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