Classification systems (TNM, AJCC, misc) Flashcards
BIRADS
BIRADS
0: Incomplete, need repeat or additional
1: negative, normal, reg surveillance
2: Benign, zero percent probability of malignancy
3: Probably benign MMG, <2% probability, shorter f/u i.e. 6 months
4: Suspicious for malignant 2-94% malignant, further investigation
5: Highly suggestive for malignancy, biopsy
6: Known malignant lesion
How can you classify benign breast disease? What is in each group?
Aberations of normal breast development and involution.
- Non-proliferative
- Cyst
- Mild duct hyperplasia
- Fibroadenoma
- PASH (pseudoangiomatous hyperplasia)
- Simple columnar alteration
- Proliferative without atypia
- Florid ductal hyperplasia
- Complex fibroadenoma
- Columnar hyperplasia
- Mammary adenosis
- Radial scar/complex sclerosing lesion
- Papilloma
- Proliferative with atypia
- Atypical ductal hyperplasia
- Atypical lobular hyperplasia
- Lobular carcinoma insitu
- Flat epithelial atypia
- Atypical papilloma
Mammographic density
- Classification for density
- A: Entirely fibrofatty tissue
- B: scattered fibroglandular density
- C :heterogeneously dense with patches of density that may obscure small lesion
- D: extremely dense breast
- Difficult to detect, independent risk factor
Choledochal cysts
Todani classification
Type 1:
The most common (>80%)
Solitary fusiform cystic dilatation of a portion extrahepatic biliary tree
Type 2:
An isolated diverticulum of the CBD
Type 3:
Choledochocele (cystic dilatation of the intraduodenal CBD)
Type 4: multiple dilatations (2nd most common)
A: Extra & intrahepatic
B: Extrahepatic
Type 5: Intrahepatic dilations (Carolis)
Cholangiocarcinoma classification macroscopic appearance & location
Bismuth-Corlette classification
Type 1: CHD below confluence
Type 2: at the confluence
Type 3: Into a hepatic duct R=A L=B (stupid)
Type 4: Confluence into both hepatic ducts
Morphology (Japanese)
Type 1: Mass forming (exophytic nodule outwards)
Type 2: Periductal infiltrating (most common)
Type 3: Intraductal (papillary within the duct)
Pancreatitis CT severity score
- Combination of 2 scoring systems
- Balthazar CT score A->E
- A normal
- B enlargement
- C inflammatory changes in the pancreas and peripancreatic fat
- D ill defined single peripancreatic fluid collection
- E 2 or more peripancreatic fluid collection
- Pancreatic necrosis score as a %
- None
- <30
- 30-50
- 50+
Hydatid classification (USS)
Severity of pancreatitis
Revised Atlanta classification:
Mild
- No local or systemic complications
- No organ failure
Moderate
- Either local or systemic complication &/or
- Transient organ failure (<48hrs)
Severe
- Either local or systemic complication &
- Persistent organ failure (>48hrs)
Modified glasgow criteria
- Modified Glasgow criteria
- > or = 3 is higher risk of M&M
- measured at 48hours
- PANCREAS
- Pa02 <60mmHg
- Age >55
- Neutrophils >15
- Calcium <2mmol/L
- Renal function – urea >16mmol/l
- Liver enzymes – AST or ALT >200 or LDH >600
- Albumin <32
- Sugar >10 BGL
TNM Pancreatic adenocarcinoma
T
- Tis: high-grade pancreatic intraepithelial neoplasia (PanIn-3), intraductal papillary mucinous neoplasm with high-grade dysplasia, intraductal tubulopapillary neoplasm with high-grade dysplasia, and mucinous cystic neoplasm with high-grade dysplasia.
- T1 <2cm
- T2 2-4cm
- T3 >4cm
- T4 involving CHA, Coeliac or SMA
N
- N0
- N1 1-3
- N2 4 or more
M
- M0
- M1 distant metastasis
- Stage
- 1a: T1
- 1b: T2
- 2a: T3 (+4cm)
- 2b: N1 (nodes)
- 3: N2 or T4
- 4: Metastatic disease
- 7 out of 10 patients do not receive any time of active treatment, 1 in 10 will have potentially curative surgery
- Majority present at late stage – unresectable – 5 year survival 7%
- Resectable disease (<20% of patients)
- Overall, median survival 12-24 months, 10-25% 5 year overall survival
- R0 resection with >1mm margin – median 35 months
- R0 resection with <1mm margin – median 16 months
- R1 resection – median 14 months
- Metastatic disease
- 6 months median without treatment
- 11 months median with treatment
Grade oesophageal varices
Grade 1-3
Small, collapse on insufflation with air
Moderate, don’t collapse on insufflation
Large, occluding lumen
Classification of gastric varices
Sarin classification
- GOV1:
- Extending <5 cm from GOJ into stomach
- Treated with EBL
- GOV2:
- Extending from GOJ into fundus
- IGV1:
- Isolated varices in gastric fundus
- IGV2:
- Isolated non-fundic gastric varices
- GOV2 and IGV1-2 treated with Injection of cyanoacrylate or thrombin
All respond well TIPS
IGV 1 associated with splenic vein thrombosis, consider splenectomy or SAE
(* The splenic artery remains intact and thus enables continued high pressure in the spleen, which forces an abnormal outlet through collaterals.
* Increased blood flow through the short gastric veins to the coronary vein or through the gastroepiploic vein to the pancreaticoduodenal vein creates a localized form of “left-sided” portal hypertension with dilatation of the submucosal veins within the stomach wall, producing the formation of gastric varices along the greater curvature and the fundus of the stomach.
* The oesophageal veins can usually drain through the patent coronary vein, so the development of associated oesophageal varices is prevented)
Childs pugh score
- Childs Pugh
- 5 factors (2 clinical and 3 biochemical)
- 2 clinical
- Ascites
- 1: absent
- 2: managed with medication
- 3: refractory
- Encephalopathy
- Agitation, reverse sleep wake, lethargy, confusion/coma
- 1: None
- 2: grade 1-2 or supressed with medications
- 3: 3+ or refractory
- 3 biochemical
- Bilirubin
- 1: <34
- 2: 34-50
- 3: 50+
- Albumin
- 1: 35+
- 2: 28-35
- 3: <28
- INR
- 1: <1.7
- 2: 1.7-2.2
- 3: 2.2+
- Total score:
- Class A
- 5-6 points
- 100% survival
- Elective laparotomy 90 day mortality <10%
- Emergency laparotomy 90 day mortality 20%
- Class B
- 7-9 points
- 80% survival
- Elective laparotomy 90 day mortality 20%
- Emergency laparotomy 90 day mortality 30%
- Class C
- 10-15 points
- 45% survival
- Elective laparotomy 90 day mortality 50%
- Emergency laparotomy 90 day mortality 80%
- Limitations
- Subjective
- Decompensation can occur in CP A
- Doesn’t predict mortality
- B is very broad!
TNM gallbladder carcinoma
Gallbladder has no submucosa
T1a: invades lamina propria
T1b: invades muscularis propria
T2a: invades perimuscular tissues on peritoneal side
T2b: invades perimuscular tissues on liver side
T3: penetrates the visceral peritoneum (serosa on peritoneal side), or invades the liver +/- 1 adjacent extrahepatic structure
T4: invades main portal vein, hepatic artery, or 2 extrahepatic structures
Cholangitis Toyko guidelines 2018
**Make diagnosis **
* A: Inflammation (systemic)
* Fever >38C
* Bloods
* <4 WCC 10<
* 1< CRP
- B: Cholestasis
- Bilirubin >20
- Raised liver enzymes >1.5
- C: Radiological
- Biliary dilatation
- Aetiology of obstruction
*** Degree of certainty **
Suspected
* One in A plus
* One in B or C
Definite
* One in A, B and C
**Assess severity **
Mild
* Not moderate or severe
Moderate (no organ markers here)
* WCC >12 or <4
* High fever >39
* Age >75
* Bili >50
* Albumin low
Severe
* Cardiovascular (inotropes)
* Respiratory(PaO2/FiO2 ratio <300)
* Neurological disturbance
* Renal (oligouria or creatinine >200)
* Hepatic dysfunction (INR>1.5)
* Haematological dysfunction (platelets <100)
Mirizzi syndrome
- Csendes (pronounce ~sen dez) classification
- Cholecystobiliary fistula
- Type I: No fistula (compression)
- Type II: 1/3 CHD
- Type III: 2/3 CHD
- Type IV: 3/3 CHD
- Cholecystoenteric fistula
- Type V
- Treatment:
- Treat the sepsis, CrRISP principles, IVABx, biliary drainage ERCP/PTC preoperatively
- Depends on type
- Type I:
- Partial or total cholecystectomy, either laparoscopic or open. Common bile duct exploration is typically not required.
- Type II:
- Cholecystectomy plus closure of the fistula,
- Either by suture repair with absorbable material
- T tube placement
- Or choledochoplasty with the remnant gallbladder
- Type III:
- Will need some degree of reconstruction
- Choledochoplasty or bilioenteric anastomosis (choledochoduodenostomy, cholecystoduodenostomy, or choledochojejunostomy) depending on the size of the fistula. Suture of the fistula is not indicated.
- Type IV:
- Bilioenteric anastomosis, typically choledochojejunostomy, is preferred because the entire wall of the common bile duct has been destroyed.
TNM staging colorectal
T; depth of tumour invasion
T1; into submucosa
T2; into muscularis propria
T3; through muscularis propria into surrounding pericolic tissues
T4a; penetrates through the adventitia (retroperitoneal) or visceral peritoneum/serosa (<-same thing)
T4b; into surrounding organs or structure
–
N0
N1; 1-3
N2; 4+
–
M0
M1; distant site or peritoneal surface
Risk of lymph node metastasis in malignant colorectal polyp
- Haggit classification
- Level of invasion into a pedunculated polyp
- Sessile polyps are level 4
- Risk of LN metastasis
- Level1-3: very low
- Level 4 only: 12-25% (need resection)
- Kikuchi level (see diagram below)
- Used for sessile polyps
- Submucosa divided up into thirds (sm1,2,3)
- SM1: 2%
- SM2: 8%
- SM3: 28%
- Note above [2 + 8 = 28] for Kikuchi & Level 4 is the same as Kikuchi, so it depends, but is up to 28%
Scoring tool for severity of lower GI bleed
Oakland score
Recommended by the british gastro and colorectal surgeons
Hydradenitis suppurativa - classification
The Hurley system, the most widely used assessment tool, describes three clinical stages.
Stage I: solitary or multiple isolated abscess formation without sinus tracts or scarring.
Stage II: Recurrent abscesses, single or multiple widely spaced lesions, with sinus tract formation.
Stage III: Diffuse involvement of an area with multiple interconnected sinus tracts and abscesses.
Le Forte fractures
- Must have pterygoid fracture to be a le fort fracture
- 3 is floating midface
Types
• 1:
o Separation of alveolar process from body of maxilla
o Fracture extends to anterolateral margin of nasal fossa
• 2:
o Pyramid shape, teeth being the base and nasofrontal suture the apex
o Cross inferior orbital rim, orbital floor and medial orbital wall
o Anterior and lateral walls of the maxillary sinuses fractures
• 3:
o Separation of the bones of the face from the skull
o Upper posterior maxillary sinuses are fractured along with zygomatic arch, lateral orbital wall and lateral orbital rim
o Fracture at junction of frontal bone and greater wing of the sphenoid, and across the nasofronatal suture
Neck zones
AAST pancreatic injury
1: mild contusion or laceration (not involving duct)
2: major contusion or laceration (not involving duct)
3: transection of the distal* duct
4: transection of the proximal* duct or ampulla
5: massive disruption of the pancreatic head
* proximal/distal to the SMV crossing
AAST aortic injury
