GenSurg 2 Flashcards
Cancers: Adrenal adenoma, Breast cancer, Lung cancer
Approximately what % of adrenal tumours are hormonally active, and what % need resection?
Approx 30% are hormonally active, and approx 14% require resection
What are the key objectives in the evaluation of adrenal mass?
Detect malignancy
Detect hormonal activity
What are the SSx of Cushing’s?
Truncal obesity HTN DM Osteoporosis (or # Hx) Hirsutism Easy bruising Weakness
What are the SSx of aldosteronoma?
HTN
Headaches
Muscle weakness
Hx of hypokalemia
What are the SSx of pheochromocytoma?
HTN Headaches Excessive sweating Palpitations Weight loss Paroxyms (sudden episodes: sweating, palpitations, general discomfort, headaches)
What are the SSx of sex hormone tumours?
Virilization (Ask about Menstrual Hx, Hirsutism, shaving frequency in men)
Feminisation
Change in sexual function possible indicator
Relative to other etiologies of adrenal masses, how common are sex hormone secreting tumours?
Rare
What are the categories of hormones that an adrenal mass might secrete?
Cortisol, corticosteroids
Catechoalamines (pheo) Aldosterone
Sex hormone tumours
What labs would be considered if there is concern of aldosteronoma?
- Plasma aldosterone/renin ratio
- Serum potassium
What labs would be considered if there is concern of cortisol-secreting mass?
Dexamethasone suppression test
What labs would be considered if there is concern of neuroendocrine tumour?
Urinary/serum metanephrines and normetanephrines
What role do CT and MRI play in assessing adrenal masses?
May be able to differentiate benign from malignant (density on CT, some features on T2)
What is venography with serum sampling useful for?
Bilateral adrenal masses: extract blood from adrenal veins, & side secreting lots of hormone is the side to surgically resect
How does size relate to cancer risk in adrenal masses?
<4cm: usually benign (<2% are malignant)
4-6cm: careful evaluation
>6cm: Often malignant (25% are malignant)
What patients always get surgery for adrenal masses?
Those with pheochromocytoma, and those with symptoms
Abn labs may or may not warrant surgery for cortisol and aldosterone secretion
What is an immediate concern following removal of a cortisol-secreting tumor?
Addison’s crisis: acute post-op hypotension (contralateral adrenal gland is suppressed)
What is the treatment for Addison’s crisis?
IV steroids (fluids won’t work)
May require PO steroids for up to 9mo
What is a post-op concern after removal of an aldosterone-secreting tumour?
If patient is on medication for hypertension, may need adjustment
Monitor serum potassium
For which adrenal masses is longer term follow-up indicated?
Pheo (monitor for MEN syndrome)
Cancer (recurrence, metastasis)
In adrenal glad resection, which vessels are clipped and which are cauterized?
Vein is clipped, arteries are cauterized
What are the two main origins of breast cancer?
Ductal carcinoma (most common) Lobular carcinoma ( ~ 10% of BrCA cases)
What is the stage progression of ductal carcinoma?
- Ductal hyperplasia
- Atypical ductal hyperplasia
- Ductal carcinoma in situ (DCIS – neoplastic)
- DCIS with microinvasion (started to break through walls of duct)
- Invasive ductal cancer
Why are breast cells particularly vulnerable to malignant tranformation?
Metabolically active
Subject to hormonal stimulation
What risk factors carry a relative risk of >4 for BrCA?
- 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
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)
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
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)
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.
What are suspicious abnormalities on mammography? Name 4.
Irregular masses
Pleomorphic calcifications
Asymmetric density
Architectural distortion
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)
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
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
What is the difference in survival outcome for mastectomy vs lumpectomy?
No difference
What is the difference in recurrence for mastectomy vs lumpectomy (in BrCA)?
Rates of local recurrence:
Mastectomy <5%
Lumpectomy alone: 35%
Lumpectomy + radiation: <10%
How is axillary lymph node staging done in BrCA?
Full axillary dissection, or sentinel lymph node biopsy
SLN: less invasive, lower complication risk
What are potential short term complications of BrCA resection?
Infection bleeding seroma poor wound healing nerve injury (long thoracic or throacodorsal)
What are potential long-term complications of BrCA resection?
lymphedema
range of motion impairment
body image
chronic pain syndrome
What single type of cancer kills the most patients?
Lung cancer
Why is lung cancer so often deadly?
Usually not found until advanced stages: 60% present in stage IV
What types of primary lung cancer are there?
Small cell (30%)
Non-small-cell (70%)
- Squamous cell
- Adenocarcinoma
Why is small cell lung cancer particularly difficult?
Almost always systemic
Multifocal, often metastatic
Often have paraneoplastic syndrome (eg SIADH, LEMS)
What makes small cell lung cancer have a poor prognosis?
After initial response to treatment, becomes resistant
Are more lung cancers primary or metastases?
Metastases
What is the overall approach to history in a patient being evaluated for lung cancer?
Local symptoms Systemic Sx (?Metastases) Cardio-resp functional assessment
What are potential local Sx of lung CA?
Cough, hemoptysis, chest pain, hoarseness, SOB
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
What history can give info about the cardio-resp functional assessment?
Stair climbing (good surrogate for exercise tolderance) Concomitant CV disease (angina, claudication)
What exposures are important to ask about on a Hx for lung CA?
Toxins: Smoking, Radon, Asbestos
Infectious: TB, histoplasmosis
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
What labs evaluate lung cancer?
CBC, lytes
Serum Ca & Alk Phos (?bone mets)
Consider ABG for physiologic testing
What imaging should be done for lung cancer?
CT with IV contrast
PET scan
How is tissue biospy taken for lung CA?
Bronchoscopy
CT guided core biopsy
Endobrachial ultrasound
Endoesophageal ultrasound
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
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?
Name 4 potentially life-threatening early complications of lung CA resection
Pneumonia / resp failure
Cardiac arrythmia
Air leaks
Bleeding
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
What is the long-term followup for lung cancer?
No general consensus.
Frequent CT not indicated, but long-term CT may detect CA early.
What is TNM staging?
Tumor, Node, Metastasis staging
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)
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
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.
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
