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GenSurg 2 Flashcards

Cancers: Adrenal adenoma, Breast cancer, Lung cancer

1
Q

Approximately what % of adrenal tumours are hormonally active, and what % need resection?

A

Approx 30% are hormonally active, and approx 14% require resection

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2
Q

What are the key objectives in the evaluation of adrenal mass?

A

Detect malignancy

Detect hormonal activity

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3
Q

What are the SSx of Cushing’s?

A 
Truncal obesity
HTN
DM
Osteoporosis (or # Hx)
Hirsutism
Easy bruising
Weakness
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4
Q

What are the SSx of aldosteronoma?

A

HTN
Headaches
Muscle weakness
Hx of hypokalemia

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5
Q

What are the SSx of pheochromocytoma?

A 
HTN
Headaches
Excessive sweating
Palpitations
Weight loss
Paroxyms (sudden episodes: sweating, palpitations, general discomfort, headaches)
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6
Q

What are the SSx of sex hormone tumours?

A

Virilization (Ask about Menstrual Hx, Hirsutism, shaving frequency in men)
Feminisation

Change in sexual function possible indicator

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7
Q

Relative to other etiologies of adrenal masses, how common are sex hormone secreting tumours?

A

Rare

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8
Q

What are the categories of hormones that an adrenal mass might secrete?

A

Cortisol, corticosteroids
Catechoalamines (pheo) Aldosterone
Sex hormone tumours

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9
Q

What labs would be considered if there is concern of aldosteronoma?

A
  • Plasma aldosterone/renin ratio

- Serum potassium

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10
Q

What labs would be considered if there is concern of cortisol-secreting mass?

A

Dexamethasone suppression test

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11
Q

What labs would be considered if there is concern of neuroendocrine tumour?

A

Urinary/serum metanephrines and normetanephrines

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12
Q

What role do CT and MRI play in assessing adrenal masses?

A

May be able to differentiate benign from malignant (density on CT, some features on T2)

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13
Q

What is venography with serum sampling useful for?

A

Bilateral adrenal masses: extract blood from adrenal veins, & side secreting lots of hormone is the side to surgically resect

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14
Q

How does size relate to cancer risk in adrenal masses?

A

<4cm: usually benign (<2% are malignant)
4-6cm: careful evaluation
>6cm: Often malignant (25% are malignant)

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15
Q

What patients always get surgery for adrenal masses?

A

Those with pheochromocytoma, and those with symptoms

Abn labs may or may not warrant surgery for cortisol and aldosterone secretion

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16
Q

What is an immediate concern following removal of a cortisol-secreting tumor?

A

Addison’s crisis: acute post-op hypotension (contralateral adrenal gland is suppressed)

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17
Q

What is the treatment for Addison’s crisis?

A

IV steroids (fluids won’t work)

May require PO steroids for up to 9mo

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18
Q

What is a post-op concern after removal of an aldosterone-secreting tumour?

A

If patient is on medication for hypertension, may need adjustment

Monitor serum potassium

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19
Q

For which adrenal masses is longer term follow-up indicated?

A

Pheo (monitor for MEN syndrome)

Cancer (recurrence, metastasis)

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20
Q

In adrenal glad resection, which vessels are clipped and which are cauterized?

A

Vein is clipped, arteries are cauterized

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21
Q

What are the two main origins of breast cancer?

A 
Ductal carcinoma (most common)
Lobular carcinoma ( ~ 10% of BrCA cases)
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22
Q

What is the stage progression of ductal carcinoma?

A
  • Ductal hyperplasia
  • Atypical ductal hyperplasia
  • Ductal carcinoma in situ (DCIS – neoplastic)
  • DCIS with microinvasion (started to break through walls of duct)
  • Invasive ductal cancer
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23
Q

Why are breast cells particularly vulnerable to malignant tranformation?

A

Metabolically active

Subject to hormonal stimulation

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24
Q

What risk factors carry a relative risk of >4 for BrCA?

A
  • Female
  • Age (65+)
  • BrCA mutations
  • 2+ first-degree relatives with BrCA Dx at early age
  • Personal Hx of BrCA
  • High density breast tissue
  • Biopsy-confirmed atypical hyperplasia
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25
What risk factors carry a relative risk of 2.1-4 for BrCA?
- One first-degree relative with breast cancer - High-dose radiation to chest - High bone density (postmenopausal)
26
What risk factors carry a relative risk of 1.1-2 for BrCA?
Many factors related to hormone levels (e.g. early menarche, late first pregnancy, late menopause, OCP, HRT) Also: - Personal Hx of endometrium, ovary, or colon CA - Alcohol consumption - Height (tall) - High SES - Jewish heritage
27
What happens to the risk of dying of BrCA as a person ages?
Decreases (risk of getting it increases, but risk of dying of it decreases)
28
What is the "triple test" in BrCA?
used to evaluate suspicious findings on clinical exam or imaging. Consists of clinical exam, imaging, and tissue sample.
29
What are suspicious abnormalities on mammography? Name 4.
Irregular masses Pleomorphic calcifications Asymmetric density Architectural distortion
30
What imaging methods are available for imaging breast tissue?
Mammogram Ultrasound (better in dense tissue) Contrast-enhanced MRI (more sensitive, less specific: high false positive rate)
31
What are the options for tissue sample (in BrCA)?
Percutaneous (guided by palpation, US, mammogram, possibly MRI) Excisional (Larger; surgery) If at all possible do percutaneous
32
What factors affect choice of lumpectomy vs mastectomy?
Extent of breast disease (Breast to tumor size ratio, Unifocal vs multicentric disease) Suitability for radiation (Ability to spend the time/travel, Prior radiation, Collagen vascular disease) Patient choice
33
What is the difference in survival outcome for mastectomy vs lumpectomy?
No difference
34
What is the difference in recurrence for mastectomy vs lumpectomy (in BrCA)?
Rates of local recurrence: Mastectomy <5% Lumpectomy alone: 35% Lumpectomy + radiation: <10%
35
How is axillary lymph node staging done in BrCA?
Full axillary dissection, or sentinel lymph node biopsy SLN: less invasive, lower complication risk
36
What are potential short term complications of BrCA resection?
``` Infection bleeding seroma poor wound healing nerve injury (long thoracic or throacodorsal) ```
37
What are potential long-term complications of BrCA resection?
lymphedema range of motion impairment body image chronic pain syndrome
38
What single type of cancer kills the most patients?
Lung cancer
39
Why is lung cancer so often deadly?
Usually not found until advanced stages: 60% present in stage IV
40
What types of primary lung cancer are there?
Small cell (30%) Non-small-cell (70%) - Squamous cell - Adenocarcinoma
41
Why is small cell lung cancer particularly difficult?
Almost always systemic Multifocal, often metastatic Often have paraneoplastic syndrome (eg SIADH, LEMS)
42
What makes small cell lung cancer have a poor prognosis?
After initial response to treatment, becomes resistant
43
Are more lung cancers primary or metastases?
Metastases
44
What is the overall approach to history in a patient being evaluated for lung cancer?
``` Local symptoms Systemic Sx (?Metastases) Cardio-resp functional assessment ```
45
What are potential local Sx of lung CA?
Cough, hemoptysis, chest pain, hoarseness, SOB
46
What systemic SSx should be inquired about in a history for lung cancer?
``` Lymphadenopathy Brain mets: Headaches, balance, or vision changes Bone mets: Bone pain or fractures Abdo: Abdo pain, jaundice, mass General: Weight loss, B Sx ```
47
What history can give info about the cardio-resp functional assessment?
``` Stair climbing (good surrogate for exercise tolderance) Concomitant CV disease (angina, claudication) ```
48
What exposures are important to ask about on a Hx for lung CA?
Toxins: Smoking, Radon, Asbestos Infectious: TB, histoplasmosis
49
What is the overall approach tot he physical exam of a patient with suspected lung cancer?
Oncologic: r/o metastases Cardioresp: assess suitability for surgery, and for lung resection
50
What labs evaluate lung cancer?
CBC, lytes Serum Ca & Alk Phos (?bone mets) Consider ABG for physiologic testing
51
What imaging should be done for lung cancer?
CT with IV contrast | PET scan
52
How is tissue biospy taken for lung CA?
Bronchoscopy CT guided core biopsy Endobrachial ultrasound Endoesophageal ultrasound
53
What is the gold standard for lymph node staging in lung CA?
Cervical mediastinoscopy; complications have led to more endobrachial ultrasound-guided transbronchial needle aspiration
54
What two main questions guide the decision to treat lung CA surgically?
Is the tumor resectable and not metastatic? | Does the patient have the cardiopulmonary reserve to tolerate surgery?
55
Name 4 potentially life-threatening early complications of lung CA resection
Pneumonia / resp failure Cardiac arrythmia Air leaks Bleeding
56
What is the rare but potentially catastrophic post-lung-resection complication for which clinicians should have a high index of suspicion?
Bleeding. Chest tube output drops off: monitor chest tube! Stat CBC and CXR if suspected
57
What is the long-term followup for lung cancer?
No general consensus. Frequent CT not indicated, but long-term CT may detect CA early.
58
What is TNM staging?
Tumor, Node, Metastasis staging
59
What is T staging in lung CA?
Based on tumour size T1: < 3cm T2: 3-7cm T3: > 7cm (invasion of chest wall, pleura, diaphragm, or main bronchus) T4: Invasion of vital structures (heart, aorta, vertebrae, carina)
60
What is N staging in lung cancer?
Node staging N0: no nodes N1: ipsilateral hilar nodes N2: ipsilateral mediastinal nodes N3: contralateral mediastinal, scalene, or supraclavicular nodes
61
What is the overall prognosis for newly diagnosed lung cancer?
Poor: - 80% of patients die within two years of diagnosis - < 10% of those diagnosed with lung cancer survive five years.
62
What postop pulmonary complication can be related to poor pain control?
Pneumonia Poor pain control leads to decreased respiratory efforts, atelectasis, retention of secretions, and pneumonia

Surgery (11 decks)

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