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Surgery > GenSurg 2 > Flashcards

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
Q

What risk factors carry a relative risk of 2.1-4 for BrCA?

A
  • One first-degree relative with breast cancer
  • High-dose radiation to chest
  • High bone density (postmenopausal)
26
Q

What risk factors carry a relative risk of 1.1-2 for BrCA?

A

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
Q

What happens to the risk of dying of BrCA as a person ages?

A

Decreases (risk of getting it increases, but risk of dying of it decreases)

28
Q

What is the “triple test” in BrCA?

A

used to evaluate suspicious findings on clinical exam or imaging. Consists of clinical exam, imaging, and tissue sample.

29
Q

What are suspicious abnormalities on mammography? Name 4.

A

Irregular masses
Pleomorphic calcifications
Asymmetric density
Architectural distortion

30
Q

What imaging methods are available for imaging breast tissue?

A

Mammogram
Ultrasound (better in dense tissue)
Contrast-enhanced MRI (more sensitive, less specific: high false positive rate)

31
Q

What are the options for tissue sample (in BrCA)?

A

Percutaneous (guided by palpation, US, mammogram, possibly MRI)
Excisional (Larger; surgery)

If at all possible do percutaneous

32
Q

What factors affect choice of lumpectomy vs mastectomy?

A

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
Q

What is the difference in survival outcome for mastectomy vs lumpectomy?

A

No difference

34
Q

What is the difference in recurrence for mastectomy vs lumpectomy (in BrCA)?

A

Rates of local recurrence:
Mastectomy <5%
Lumpectomy alone: 35%
Lumpectomy + radiation: <10%

35
Q

How is axillary lymph node staging done in BrCA?

A

Full axillary dissection, or sentinel lymph node biopsy

SLN: less invasive, lower complication risk

36
Q

What are potential short term complications of BrCA resection?

A 
Infection
bleeding
seroma
poor wound healing
nerve injury (long thoracic or throacodorsal)
37
Q

What are potential long-term complications of BrCA resection?

A

lymphedema
range of motion impairment
body image
chronic pain syndrome

38
Q

What single type of cancer kills the most patients?

A

Lung cancer

39
Q

Why is lung cancer so often deadly?

A

Usually not found until advanced stages: 60% present in stage IV

40
Q

What types of primary lung cancer are there?

A

Small cell (30%)

Non-small-cell (70%)

  • Squamous cell
  • Adenocarcinoma
41
Q

Why is small cell lung cancer particularly difficult?

A

Almost always systemic
Multifocal, often metastatic
Often have paraneoplastic syndrome (eg SIADH, LEMS)

42
Q

What makes small cell lung cancer have a poor prognosis?

A

After initial response to treatment, becomes resistant

43
Q

Are more lung cancers primary or metastases?

A

Metastases

44
Q

What is the overall approach to history in a patient being evaluated for lung cancer?

A 
Local symptoms
Systemic Sx (?Metastases)
Cardio-resp functional assessment
45
Q

What are potential local Sx of lung CA?

A

Cough, hemoptysis, chest pain, hoarseness, SOB

46
Q

What systemic SSx should be inquired about in a history for lung cancer?

A 
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
Q

What history can give info about the cardio-resp functional assessment?

A 
Stair climbing (good surrogate for exercise tolderance)
Concomitant CV disease (angina, claudication)
48
Q

What exposures are important to ask about on a Hx for lung CA?

A

Toxins: Smoking, Radon, Asbestos

Infectious: TB, histoplasmosis

49
Q

What is the overall approach tot he physical exam of a patient with suspected lung cancer?

A

Oncologic: r/o metastases
Cardioresp: assess suitability for surgery, and for lung resection

50
Q

What labs evaluate lung cancer?

A

CBC, lytes
Serum Ca & Alk Phos (?bone mets)

Consider ABG for physiologic testing

51
Q

What imaging should be done for lung cancer?

A

CT with IV contrast

PET scan

52
Q

How is tissue biospy taken for lung CA?

A

Bronchoscopy
CT guided core biopsy
Endobrachial ultrasound
Endoesophageal ultrasound

53
Q

What is the gold standard for lymph node staging in lung CA?

A

Cervical mediastinoscopy; complications have led to more endobrachial ultrasound-guided transbronchial needle aspiration

54
Q

What two main questions guide the decision to treat lung CA surgically?

A

Is the tumor resectable and not metastatic?

Does the patient have the cardiopulmonary reserve to tolerate surgery?

55
Q

Name 4 potentially life-threatening early complications of lung CA resection

A

Pneumonia / resp failure
Cardiac arrythmia
Air leaks
Bleeding

56
Q

What is the rare but potentially catastrophic post-lung-resection complication for which clinicians should have a high index of suspicion?

A

Bleeding.

Chest tube output drops off: monitor chest tube!

Stat CBC and CXR if suspected

57
Q

What is the long-term followup for lung cancer?

A

No general consensus.

Frequent CT not indicated, but long-term CT may detect CA early.

58
Q

What is TNM staging?

A

Tumor, Node, Metastasis staging

59
Q

What is T staging in lung CA?

A

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
Q

What is N staging in lung cancer?

A

Node staging

N0: no nodes
N1: ipsilateral hilar nodes
N2: ipsilateral mediastinal nodes
N3: contralateral mediastinal, scalene, or supraclavicular nodes

61
Q

What is the overall prognosis for newly diagnosed lung cancer?

A

Poor:

  • 80% of patients die within two years of diagnosis
  • < 10% of those diagnosed with lung cancer survive five years.
62
Q

What postop pulmonary complication can be related to poor pain control?

A

Pneumonia

Poor pain control leads to decreased respiratory efforts, atelectasis, retention of secretions, and pneumonia

Surgery (11 decks)

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