High Yield 2023 Flashcards
Pheo w/up:
- Spot plasma or urine metanephrine (sensitive)
- 24-urine metanephrine (specific)
- CT (> MRI)
- MIBG (if suspect multi-focal)
Dx and Localize a gastrinoma
Dx:
1. Off PPI: G > 1000 or >200 w/ secretin stimlation
2. Can’t get off PPI: SS Scintigraphy
Localize:
1. Triphasic CT/MRI
2. SS Scintography (Dotatate PET/CT)
3. Endoscopic US
4. Selective intra arterial Ca
5. OR: Intra-Op US, transduodenal palpation, duodenotomy, palpate HOP
Order of contents in thoracic outlet
- Subclavian VEIN
- Phrenic NERVE
- Anterior scalene MUSCLE
- Subclavian ARTERY
- Brachial plexus NERVE
- Middle scalene MUSCLE
Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst
- WON sterile: conservatively
- WON infected: step-up approach
- Pseudocyst: tx if sxs (infxn, obstruction, pain)
- 4-6w → internal drain → cyst-enterostomy - Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
Bethesda criteria for thyroid
**1 cm is cutoff to get an FNA
- Non-diagnostic → repeat FNA
- Benign → follow-up
- Undetermined significance → repeat FNA or lobectomy
- Follicular neoplasm → lobectomy
- Suspicious for malignancy → lobectomy vs. thyroidectomy
- Malignant → thyroidectomy
Cowden’s mutation and cancers
Mutation: pten
Ca: breast, thyroid ca, hamartomas, endometrial
Tx Medullary thyroid cancer
- TOTAL thyroidectomy
- > 1 cm or bilobar: central/level 6 dissection
- Lateral neck dissection on that side if central+
- Start T4 postop. Monitor w/ calcitonin AND CEA
- RAI is c/i! (C cell origin)
GCS eye opening
4- spon
3- to voice
2- to pain
1- none
Methanol and Ethylene glycol toxicity - Px and Tx
Px: profound AG metabolic acidosis
- oxalate stones → renal failure
Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD
Burn degrees
1D: epidermis
2D superficial: pap dermis, painful, hair follicles intact; blanches
- don’t need grafting
2D deep: retic dermis, decreased sensation; loss of hair follicles, no blanch
- need skin grafts
3D burn: subcutaneous fat, leathery
4D: fat/muscle/bone; surg
Dx, Bx, and Tx actinic keratosis
- Dx: red, crusty, weeping lesion
- Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
- Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
Polyps that require surgery instead of endoscopic resection
- Submucosal invasion > 1mm
- Poorly differentiated
- <1 mm margin
- LV invasion
- Tumor budding
- Taken piecemeal
T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung
- eso: select t1b (SM) or T2 (MP)
- stomach: t2 (MP)
- colon: t4b (adjacent organs)
- rectal: t3 (through MP)
- lung: n2 nodes
Screening in IBD patients
- Start 8 years after sx onset
- 2-4 random bx every 10 cm throughout the colon + suspicious areas
Repeat schedule:
- normal: q1-3 years
- PSC, stricture, or dysplasia w/out colectomy: q1 year
Any dysplasia usually gets a colectomy
- if resectable can consider endoscopic resection with close surveillance
W/up of thyroid nodule found on exam or incidental imaging
- U/S and TSH:
a. Nodule + Low TSH ➡ RAI uptake scan - hot/functioning: toxic adenoma (no cancer) ➡ thionamide, b-block + lobectomy
- cold: FNA
b. Nodule + Normal/High TSH ➡ FNA
Eso dysplasia tx
- LGD: scope q6-12m
- OK for fundoplication - HGD: ablation + Q3m scope
- fundoplication c/i - T1a: ablation
- t1b (or low risk T2): upfront esophagectomy
*Fundoplication does not decrease cancer risk
Esophagus blood supply
- Cervical- inf thyroid
- Thoracic- aortic branches (bronchial arteries)
- Abd- left gastric/inferior phrenic
TEF - MC types. dx and tx
- Type MC, 85%
- Proximal esophageal atresia (blind pouch) and distal TE fistula
- dx: AXR ➡ distended, gas-filled stomach, coiling tube
- no UGI needed! - Type A: second most common, 5%
- Esophageal atresia and no fistula
- dx: XR: gasless abdomen, coiling tube
- no UGI needed!
Tx:
1. Resuscitate w/ repogle tube
2. Echo: VACTERL cardiac w/up
3. G-tube placement to decompress and feed
4. Delayed right extra-pleural thoracotomy
5. Distal ligation of TEF (if gas in abdomen, type C)
**long term r/o dysphagia and GERD
MEN1/MEN2 genes
MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene
Birads score
0- redo imaging
1- negative, NTD
2- benign, NTD
3- benign, repeat q6m
4- suspicious, bx
5- highly suspicious, bx
6- confirmed, excise
**discordance: perform repeat bx w/ surgical excision or core bx (if there was a correctable error)
MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin
- Fluconazole: ergosterol synth inhibitor
- Non-systemic candida (yeast infection, c. albicans)
- s/e: liver toxic, GI upset - Voriconazole: ergosterol synth inhibitor
- aspergillosis, C. krusei
- s/e: visual changes, psychosis - Micafungin: echinocandin; inhibit glucan production
- invasive/disseminated candidiasis (c. glabrata)
- s/e: TCPenia - Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
- invasive mucor or cryptococcal meningitis
- s/e: nephrotoxic, hypoK
Recurrent laryngeal nerve + aberrant anatomy
- motor: larynx except cricothyroid
- sensory: larynx below the cords
- injury: hoarseness, airway compromise, permanent ADduction —> bilateral may need a trach
Aberrant anatomy:
- NR right a/w: arteria lusoria ➡ absent innominate + right SC takes off from left aortic arch
- NR left a/w R sided arch
PFTs for lung resection
- Preop FEV1 and DLCO predicted > 80% ➡ no further testing
- >.8L wedge, >1.5L lobe, >2L pneumo
- < 80% ➡ lung scan for PPO FEV1, DLCO - PPO FEV1, DLCO > 60% ➡ no further testing
- < 60% ➡ exercise test - VO2 > 10 ml/min/kg ➡ OK for surgery
- < 10 ➡ high risk for surgery
Cancer associations:
- CEA
- AFP
- CA 19-9
- CA 125
- Beta-HCG
- PSA
- NSE
- BRCA I and II
- Chromogranin A
- Ret oncogene
- CEA: colon CA
- AFP: liver CA
- CA 19-9: pancreatic CA
- CA 125: ovarian CA
- Beta-HCG: testicular CA, choriocarcinoma
- PSA: prostate CA
- NSE: small cell lung CA, neuroblastoma
- BRCA I and II: breast CA
- Chromogranin A: carcinoid tumor
- Ret oncogene: medullary thyroid CA
W/up and Tx testicular mass:
- Seminoma
- Non-seminomatous
- PE
- Ultrasound
- AFP, HCG, LDH
- Seminoma: no AFP!`
- Non-seminoma: high AFP, HCG, LDH - Inguinal orchiectomy: any patient with solid testicular mass
- Based on path/markers decide:
- Seminoma: XRT
- Non-seminomatous: retroperitoneal node dissection
**ligate cord at level of internal ring so it can later be removed with retroperitoneal node dissection
Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino
4. Fungal
- Pyogenic: after cholangitis (MC) or div’s;
- drain and abx (+mica if fungal) - Amoebic: after mexico trip (or aMazon).
- dx w/ serology/hemagglutination 1st
- metronidazole (no drain) - Echinococcal: wall Ca+ and sub-cysts
- albendazole and resect/PAIR - Fungal: 2/2 chemo/neutropenia
- perc drain + micafungin
Lynch genes and gene funtions
Genes:
- MLH1
- MSH2, MSH6
- PMS2
- EPCAM
Fxn:
DNA MM repair gene causing microsatellite instability
Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma
- Hemangioma: only if sxatic or KM syndrome
- enucleate (or resect); angioembo if active bleed - FNH: NTD
- Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
Indications for total thyroidectomy (pap and follicular)
Indications for total thyroidectomy:
- Tumor > 4cm
- Tumor 1-4cm and patient preference
- Distant mets or extra-thyroid disease
- Nodal disease
- Poorly differentiated
- Prior radiation
*micro-mets do not count as distant disease
**if thyroid lobectomy only: tx with thyroid hormone to suppress TSH, get serial U/S to monitor
Von Hippel Lindau - mechanism and surveillance
VHL gene - upreg. of VEGF
1. Brain/retinal hemangioblastoma- q2y brain MRI
2. Clear cell RCC- q1y US/MRI of abdomen
3. Pheochromocytoma- yearly metanephrines
Melanoma w/up and tx
- Punch bx or excisional bx (if small, non-sensitive area)
- MIS- 5mm margin
- <1mm- 1cm
- 1-2mm- 1-2cm
- >2mm- 2cm - Clinical positive nodes (stage 3) require FNA for confirmation
- negative: SLNBx
- positive: completion LN dissection - SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
- If SLNBx+ (stage 3): q4m US surveillance OR completion LN dissection
- LN dissection: superficial 1st. Deep if cloquets+, clinically+ positive, >3+ on SLNBx, or CT+ for deep nodes
**MOHS can be used for in-situ disease. Need 5 mm margin.
PSC vs. PBC - assocaited and tx
PSC: Male; intra/extra hepatic; onion fibrosis; chain of lakes
- a/w Ulcerative colitis, cholangioca
PBC: Female; intra hepatic; granulomas; +AMA
- a/w Sjogren, RA
tx: trx, cholesty., UDCA
- meds generally don’t help
MEN syndromes
1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD
2a- Parathyroid (PTC),MTC, Pheo (catecholamines); ret; AD
2b- Pheo, MTC, marfanoid/neuroma; ret; AD
Methemoglobinemia - px, dx and tx
Px: nitrites, Hurricane spray, fertilizers, g6PD def, seretonergic drugs
- Fe2+ to Fe3+ impairing O2 binding
Dx: blood gas measurement and pulse ox says 85%
- MethHb level > 20%
Tx: methylene blue or vitamin C (for g6pd or ser)
Tx for DVT
- unprovoked: malignancy, inherited ➡ indefinite
- provoked: surgery, travel, preg, OCP, immbility ➡ 3m
Special cases:
- ileofemoral: cather directed thrombolysis
- open thrombectomy ➡ extensive (ileofemoral) DVT OR phlegmasia
- Superficial femoral vein is a DVT
- Pregnant ➡ use Lovenox. NOAC and Coumadin are c/i
Dx and Tx Parathyroid ca
Dx: palpable neck mass + Ca > 14 is presumptive dx. Otherwise, dx intra-op based on gross features.
- FNA is not recommended
- Treat based on intra-operative gross invasion. Frozen section is not helpful.
Tx:
1. Control hypercalcemia: usually > 14
- IV fluids 1st! Then bisphosphonates
- cinacalcet (sensipar - ca mimetic)
- Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
- no chemo
- usually don’t perform any node dissection unless palpable nodes
Mechanism and Tx of thyroid dz:
1. Graves
2. TMN
3. Hashimoto’s
4. DeQuervains/Subacute
5. Reidels
- Graves: IgG stimulates TSHr ➡ hyperT
- BB, PTU, RAI ➡ thyroidectomy - TMN: chronic TSH stimulation ➡ hyperT
- BB, PTU, RAI ➡ total/subtotal thyroidectomy - Hashimoto’s: antiTPO/TG Ab ➡ hypoT
- thyroxine ➡ partial thyroidectomy - DeQuervains/Subacute: viral URI
- NSAIDS/ASA ➡ steroids - Reidels: autoimmune inflammation
- steroid, thyroxine ➡ extensive fibrosis often need surgery for compression
APC gene
- chromosome 5
- 1st mutn in adenoma to carcinoma
- mc mutation in colon ca
- a/w FAP
Carcinoid vs. GIST vs. Desmoid- cells and tx
- Carcinoid- Kulchinsky cells (enterochromaffin-like)
tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable - GIST- cajal cells
tx- resection, imantinib - Desmoid- spindle cells
tx- resect if extra-abdominal. NSAID/estrogen if intra
HLA test
- Tissue typing
- Donor organ: carries Ag (on WBC)
- Recipient body: carried Ab
Recipient serum with donor wbc
Tx MEN2A/B
- urine metanephrine to r/o pheo 1st
- tx pheo 1st w/ adrenalectomy
- Address thyroid
- 2A: total thyroid + bilateral central neck by 5y
- 2B: total thyroid + bilateral central neck by 1y
Tx MEN1
- HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
- Asses other lesions
GI Hormone Release and action:
- Glucagon
- Insulin
Glucagon: alpha cells of pancreas
- glycogenolysis, gluconeogenesis
Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis
Criteria for transanal excision of adenocarcinoma
- T0 or T1 (submucosa)
- < 3 cm
- < 30% circumference
- Palpable on DRE (<8cm from anal verge)
- No high-risk features (poorly diff, LV invasion)
**local recurrence rate is higher
HNPCC screening and treatment
- CRC: scope q1-2y starting at 20-25
- Surgery if:CRC or endoscopically unresectable lesions
- TAC with IRA w/ q1y rectum surveillance - Endometrial ca
- childbearing: endometrial sampling q1y
- after children: TAH-BSO - Ovarian ca: annual pelvic exam and TVUS
Px, Dx, and Tx:
Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro
Duo atresia: newborn; bilious emesis directly after birth
- a/w down syndrome
-dx: AXR- doube bubble
-tx: duodenoduodenostomy
TEF: newborn, spit ups. can’t place NG. resp sxs
- dx: AXR- gasless (A), gas (C)
- tx: right extra-pleural thoracotomy
Pyloric stenosis: 1-3 months; NB projectile vomiting
-dx: U/S- 4mm thick, 14 mm long
-tx: pyloromyotomy
Intussusception: 3m-3y; currant jelly stool
- dx: U/S w/ bull’s eye
- tx: air contrast enema
Malro: 1y-5y; sudden onset bilious emesis
- dx; UGI- no duo sweep (any child w/ bilious emesis)
- tx: ladd’s procedure
Conduit after esophagectomy
Stomach and Right gastroepiploic
- if you notice this is out then stop the procedure and discuss conduit options at a later time (don’t go for colon or jejunum b/c needs to be prepped)
Tx of High grade AIN/bowen’s disease of anal margin
- Cryo, curettage, 5-FU, laser
- Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin - Lifetime surveillance even if tx!
- Bowen disease = SqCC in situ = high grade AIN
- Actinic keratosis is precursor
*vs. pagers disease- excision
Types of rejection - px, path, and tx
- hyper-acute: w/in 1 hour
- path: ABO Ab (t2 HS)
- px: mottled organ
- tx: remove organ - acute cellular: days-weeks; change in organ function
- path: B or T (t4 HS)
- px kidney: lymphocytic infiltration, tubulitis
- px liver: endothelitis, portal triad lymphocytosis
- tx: increase IS or pulse steroids ➡ IVIG - chronic: months-years
- path: B or T (t4 HS)
- px kidney: interstitial fibrosis, tubular atrophy
- px liver: bile duct atrophy
- px heart: vasculopathy and atherosclerosis; 1/2 @ 10y
- px lung: bronchiolitis obliterans; 1/2 @ 5y
- tx: increase IS or re-trx (no good options)
GI Hormone Release and action:
Gastrin
Somatostatin
CCK
Secretin
VIP
- Gastrin - G cells in antrum
- ↑ HCl, IF, and pepsinogen - Somatostatin – D cells in pancreas
- inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output - CCK – I cells of duodenum
- gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells) - Secretin – S cells of duodenum
- ↑ pancreatic/GB bi release (ductal cells), inhibits gastrin release (this is reversed in patients with gastrinoma), and inhibits HCl release - VIP – pancreas and gut
- ↑ intestinal secretion (water and electrolytes) and motility
Stages of graft healing
- imbibition (direct diffusion)
- inosculation (cap beds meet)
- revascularization
EBUS accesible nodes:
2, 3, 4, 7, 10, 11, 12
- innominate seperates level 3, 4
- 4: carinal
- 7: sub-carinal
- 10: R/L hilar
-n2 nodes: 1-9
-n1 nodes: 10-14
- cannot sample 5, 6 (sub-aortic/AP window) ➡ chamberlain procedure (Parasternal mediastinotomy)
- 8 (para-eso), 9 (IPL) ➡ EUS or VATS
Order of cells in healing
- Hemostasis: PMNs (24-48h)
- PMNs: remove necrotic tissue, release ROS’s - Inflammatory: monocytes/macrophages (48-96h)
- mphage: growth factors, angiogenesis, cell proliferation
- chronic wounds arrest in this stage - Proliferative: fibroblasts (3d+)
- fblasts: collagen production and secretion - Maturation: fibroblasts (10d)
- myofibroblasts for wound contraction
Tx for cholangiocarcinoma
Tx:
1. Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion
- Consider location
- Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
- Middle ⅓: hepaticojejunostomy
- Lower ⅓: pancreaticoduodenectomy (Whipple) - Consider chemo + transplant if unresectable
IPMN - dx and tx
dx: MRI then EUS/FNA; high CEA, high amylase
tx:
1. Branched
- resect if >3 cm, sxs, or signs of malig (nodule)
- Otherwise surveillance
2. Main duct
- resect if > 1 cm or sxs (60% chance of Ca)
- 5-9 mm EUS/FNA. Resect if SOMalig
- < 5mm, surveillance MRIs
Posterior and anterior vagal trunk branches
Vagotomies
Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet
Left ➡ Anterior trunk- hepatic branch, ant laterjet
- Truncal vagotomy: transect ant/post @ distal eso
- removes lesser curve and pylorus nerve
- need pyloroplasty. high r/o dumping syndrome - Highly selective: transect @ crow’s ft, preserve laterjet
- removes innervation to lesser curvature
- preserves pylorus → no drainage procedure
- lowest morbidity
Emergent vs. Elective UC Tx
Emergent:
1. Steroids +/- abxs
2. Infliximab, Cyclosporine
3. No response, megacolon (> 6 cm), HDUS, or perf ➡ TAC with end-ileostomy
- When stabilized can perform proctectomy and IPAA
- Don’t do proctectomy in emergent situations
Elective:
- Indications: dysplasia, cancer, refractory disease
- PC w/ IPAA
** Surgery reduces: erythema nodosum, arthritis
– no effect on PSC or ank spondy
Peutz-Jeghers - px and screening
Px- intestinal hamartomas (intususpeption), pigmented oral mucosa, polyposis
- Cancers: GI tract, breast, pancreatic
- AD, STK11 mutation
Screening
- Scope @ 25y then q2 years b/c high r/o GI/pancreas ca
TOS tx
- neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
- venous- catheter-directed thrombolysis → surgical decompression
- arterial- C7/1r resection, subc artery resection/reconstruction
FAP - Dx and Tx
Dx: > 100 adenoma or < 100 w/ fam hx
- AD; APC mutation
- CA by 40
- desmoid tumors (slow growing abdominal wall mass)
Tx:
- sigmoidoscopy q1y at 10 (don’t need colonoscopy)
- EGD @ 20 or when polyps start- SB polyposis
- TAC w/ IRA or PC w/ IPAA depending on rectal involvement at about 20 (or once florid polyposis is seen)
- q1y EGD post op for duodenal cancer (MC COD)
- q1y c’scope if TAC
- polyposis/high grade dysplasia @ stump → proctectomy +/- pouch
- desmoid: resect. Anti-E if intra-abdominal
BRCA risks and tx
female breast, ovarian, male breast
I (ch17)- 60, 40, 1
II (ch13)- 60, 10, 10
Tx:
-pre-meno: offer bilateral mastectomy OR q1 MRI starting @ 25
-post meno: bilateral mastectomy + SOO + HRT until 50 (no TAH)
**SOO decrease r/o OVARIAN Ca (80%) for BRCA1/2
AND breast Ca for BRCA2 only (50%)
**No TAH!
When to operate on adrenal mass
- all functioning tumors
- all > 6 cm ➡ open resection
- if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection
**DO NOT biopsy first
Adjuvent chemo for breast ca
- Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
- echo before for cardiotox - Tamoxifen/Anastrazole: 5y for HR+ tumors
- Tamox for men - Trastuzumab- 1y for Her2/neu+ tumors
- echo before for cardiotox
Secretin vs. CCK
Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes
Tx papillary/follicar thyroid can
- Indications for total thyroidectomy:
- Tumor > 4cm
- Distant mets or extra-thyroid disease
- Poorly differentiated
- Prior radiation - Nodes dissection:
A. Lateral neck dissection: of involved compartments if palpable or bx+ nodes
B. Prophylactic neck dissection (level 6): if > 4cm, extra-thyroid invasion, +lateral nodes.
- Usually not performed for follicular - Radio iodine indications (6w post op, want TSH high)
- Only after total thyroidectomy to be effective
- For high risk tumors: tumor > 1 cm, extra-thyroidal disease
Screening guidelines for breast ca
Mammogram every 2–3 years after age 40
then yearly after 50
High-risk screening
- mammogram 10 years before the youngest age of diagnosis of breast CA in first-degree relative
Reversals:
- BB
- CCB
- Tylenol
- Benzos
- CN/Nitroprusside
- Vecuronium/Rocuronium
- Ethylene glycol
- Methemoglobinemia
- BB overdose: fluids/atropine → glucagon
- CCB: Ca + Insulin + Atropine + Pressor
- Tylenol: NAC
- Benzos: flumazenil
- CN/Nitroprusside: sodium thiosulfate, amyl nitrite
- Vecuronium/Rocuronium: sugammadex
- Ethylene glycol: femopizole and bicarb OR ethanol; iHD
- Methemoglobinemia: methylene blue
Px and tx:
Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis
- Crypto- CNS sxs in AIDs pt
tx- amphotericin - Coccidio- pulm sxs in the southwest
tx-amphotericin - Histo- pulm sxs in ohio river valley
tx- itraconazole → ampho B (only if sxs) - Mucormycosis- burns/trauma w/ bloody cough
tx- emergent debride, ampho
LN harvest/margin
eso
stomach
colon
rectum
eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm
Cohort study vs. Case control
Cohort: prosepective; exposed vs. non-exposed
RR- [a/a+b]/[c/c+d]
Case control: retrospective; diseased vs. non-diseased
OR- (a/b)/(c/d)
- good initial study to show an association
Li Fraumeni - gene, mechanism, and px
- gene: p53 mutation; TSG on Ch17; AD inheritance
- mech: cell cycle regulation at G1/S to promote apoptosis in DNA damaged cells
- px: breast ca + sarcoma b4 45
Tumor lysis syndrome - px, path and tx
Px: Common 2/2 B cell lymphoma
- hyperU, K, Ph w/ hypoCa
Path: CaPh crystal ➡ renal failure + hypoCa
tx: IV hydration ➡ iHD
NNT
NNT = 1/absolute risk reduction (ARR)
- ARR = event rate in intervention group - rate in control group
- RR = event rate in intervention / rate in null group
- RRR = (rate control - rate experimental) / rate control
Tx childhood GI disease:
- Pyloric stenosis
- Intussusception
- Duo atresia
- TEF
- Malro
- Pyloric stenosis: pyloromyotomy
- Intussusception: air contrast enema
- Duo atresia: DD or DJ
- TEF: right extrapleural thoracotomy
- Malro: LADDS proc
Dx and Tx of GIST
- Dx: MC GI Sarcoma
- EGD + FNA: SM smooth EGD mass with normal overlying mucosa and central ulcer. Stomach MC.
- Bx: cajal cells. c-KIT+
- don’t require bx if high suspicion - Tx: wedge resection (gross margin)
- can be R0 or R1 resection
- Imatinib (TK inhibitor) ➡ 5cm or >5 mitosis/50 hpf
- mitosis/hpf is most predictive of prognosis (>mets)
- neoadjuvant if need to down-stage for resection
- adjuvant for 3 years
type 1 vs. type 2 error
type 1: false positive
- say something is true (reject the null) when it’s not
- alpha = prob of type 1 error. Set at .05
- minimize by decreasing stat significance
type 2: false negative
- say something is false (do not reject the null, accept H0) when it’s true
- beta = prob of type 2 error. Set at .2
- minimize by increasing sample size/power
**power = 1 - type 2
**reject the null = “a difference exists”
Barrett’s eso surveillance
Bx: Goblet cells and columnar cells
- No dysplasia: 4 quad every 2 cm q 3-5y
- LGD: 4 quad every 1 cm q 6m
- HGD: ablation/endoscopic resection. q3m
*Fundoplication is only c/i in HGD
*No screening if asx
HNPCC vs. Lynch S
Dx and Screening
HNPCC: fulfill amsterdam criteria
- 3+ relatives with Lynch syndrome-associated cancers (CRC, endometrium, small bowel, ureter, renal)
- 2 generations
- 1 ca dx < 50 yo
Lynch syndrome: refers to mutation in DNA MM repair gene (MLH1, MSH2, MSH6, PMS2) or the EPCAM gene.
- should test in all with new onset CRC
GCS motor
6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - ‘flex your core’
2- extension (decErebrate)
1- none
MCCO healthcare infection:
- HAP/VAP
- central line infection
- SSI
- UTI
- GI infection
- SBP
- Cholangitis
- NSTI
- ICU infection
- Fungal infection
- graft infection
- HAP/VAP: staph aureus (pseudomonas #2)
- central line infection: coag negative staph (staph epi)
- SSI: staph aureus
- UTI: e. coli
- GI infection: c. diff
- SBP: e. coli
- Cholangitis: e. coli
- NSTI: polymicrobial
- ICU infection: VAP
- Fungal infection: hitsto (asperg if I/C)
- graft infection: staph aureus (early), staph epi (late)
Tx SqCC of anal canal
- Nigro protocol- RTx (of Ca + inguinal/pelvic nodes) + 5FU + MitoC
- Recurrence (10-20%): must wait at least 6 month to diagnose ➡ salvage APR
- Lateral to I/S groove (anal margin): tx like skin cancer
SqCC equivalents- large cell ker. (SqCC), transitional zone, LCl non-ker, basaloid, mucoepidermoid
T staging for esophageal cancer
t1a: muscularis mucosa: endo resection
t1b: SM: upfront esophagectomy (or low grade t2)
t2: muscularis propria: neoadjuvant
- low risk: upfront esophagectomy
t3: adventitia: neoadjuvant
*no serosa. Ca spread through SM lymphatics
MOA and s/e of trx meds
- Tacro
- Cyclosporine
- Sirolimus
Tacro: calcineurin inhibitor; bind fK ➡ calcineurin ➡ block IL2
- 100x more potent than cyclosporine
- neuro sxs (tremor), GI sxs
- nephrotox, hepatotoxic
- DM
- alopecia
Cyclosporine: calcineurin inhibitor; bind cyclophillin ➡ calcineurin ➡ block IL2
- nephrotox, hepatotox, neuro sxs
- gingival hyperplasia, hypertrichosis
- cycled in bile, gallstones
Sirolimus: bind fK ➡ mTor inhibitor (IL2 inhibitor)
- impaired wound healing
- interstitial lung disease
- lymphocele
Post polypectomy screening
-2-6m: piecemeal removal
-1 year: > 10 adenomas
-3 years: 3+ adenomas, HGD, > 1cm, villous elements
-5 years: 1-2 tubular adenomas (< 1cm)
-10 years: hyperplastic polyps (<20)
Tx papillary/follicar thyroid ca
Start with lobectomy
Indications for total thyroidectomy:
- Tumor > 4 cm (1-4 cm, close observation or total)
- Extra-thyroidal disease
- Multi-centric or bilateral lesions
- Previous XRT
Consider ppx level 6 for high risk
If thyroid lobectomy only:
- Tx with thyroid hormone to suppress TSH
- Get serial U/S to monitor
Indications for MRND
- extra thyroid extension
Radio iodine indications (6w post op, want TSH high)
- Consider for 1-4 cm, definitely > 4cm
- Extra-thyroidal disease
- Need total thyroidectomy to be effective
GCS verbal
5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none
Esophageal CA tx
- HGD, TIS, T1a: endoscopic ablation/resection
- T1b: upfront esophagectomy or endo ablation (if low risk)
- T2 or N: neoadjuvant then esophagectomy
- Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso - T4b or M: definitive chemo-XRT
< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy
Tx of psuedoaneurysm
tx:
< 2cm observe
> 2cm:
- skinny neck: thrombin injection
- wide neck: operative intervention
Surgery for complicated disease:
- infxn (cellulitis)
- skin necrosis, skin changes
- neuro deficit, AMS
- HDUS, pulsatile,
Nerve injuries during CEA:
- Recurrent laryngeal
- Marginal mandibular
- Hypoglossal nerve
- G/Ph nerve
- Superior laryngeal
- Accessory
- Recurrent laryngeal: MC cranial nerve; 2/2 clamping; hoarseness
- Marginal mandibular: excessive retraction and angle of jaw; Ipsilateral lip palsy
- Hypoglossal nerve: ipsilateral tongue deviation
- G/Ph nerve: from high dissection; difficult swallowing
- Superior laryngeal: high-pitch
- Accessory: failure to shrug shoulders
Tx of Complications after Billroth 2:
- Afferent limb obstruction
- Dumping syndrome
- Alk reflux
- Afferent limb obstruction: prevent with afferent limb < 20 cm
- acute: convert Bil 1 or REY (STAT!)
- chronic: Bacterial overgrowth: try abxs 1st (Rifaximin)
. convert to REY - Dumping syndrome: small meals, no sugar –> octreotide
- Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
- pro-kinetics, bile-acid binding ➡ convert to REY with long roux
Primary fuel source in fasting state
- 1st 4 hours: exogenous glucose
- 4h-1d: Liver glycogen
- 1d-1w: gluconeogenesis phase (alanine from muscle)
- 1w+: protein-sparing phase
- FA/Ketones are used everywhere
- RBCs use glucose only
Essential fatty acids and immuno-nutrition
- Linoleic acid- omega-6 (Cis, Unsturated)
- inflammatory - α-linolenic acid- omega-3 (Cis, Unsturated)
- anti-inflammatory
Immuno-nutrition = arginine, omega-3 FA
- a/w less infections, shorter LOS
BSC vs. SqCC - dx and tx
BSC: most common malignancy in USA; pearly, rolled borders, peripheral palisading; MC upper lip ca
SqCC : scaly patch; keratin pearls, parakeratosis, full-thickness pleomorphism (partial = AK); MC lower lip ca
- MC ca after trx
Tx:
- 4 mm for unaggressive: well differentiated and < 2 cm
- 8 mm for aggressive: poorly differentiated or > 2cm
- 1 mm for MOHS
- MOHS for aggressive subtypes
- LADN’y for clinical positive nodes
- Can consider SLNBx for high risk SqCC
- Limited role for chemo/XRT
Dx and Tx of Ewing Sarcoma
Dx: “onion skin” in diaphysis
- pelvis is MC location
Tx: chemotherapy (1st line) + surgery or XRT
W/up and Causes of low UOP after kidney trx
w/up:
1. doppler U/S: check vasc/urteter mosis, bladder outlet obstruction
2. empiric fluid bolus
Causes
1. Immediate: arterial thrombosis- nephrectomy
2. Weeks: lymphocele- open/lap peritoneal window
3. Months: polymovirus (BK)- nephrostomy + reconstruction
Dx and Tx:
1. TG duct cyst
2. Brachial cleft cyst
3. Cystic hygroma
- TG duct: midline through hytoid bone; sistrunk procedure
- if infected tx w/ abxs first - Brachial cleft: anterior SCM; resection
- 2nd cleft cyst MC (mid/lower neck) - Cystic hygroma: posterior triangle; resection (avoid infection)
Dx and Tx of Addison’s
Cause- AI attack of adrenal cx
Labs- hypoNa, hyperK
Dx: cosyntropin stim test - cortisol remains low
- deceased cortisol and aldo with high ACTH
Tx- steroids
Px and W/up of Hypercortisolism (Cushing’s syndrome)
px: moon facies, striae
- Initial tests: choose 1-2
- 24h urine free cortisol (most se)
- late night salivary cortisol (when cortisol is lowest)
- overnight 1 mg dexa suppression - ACT Level
A. ACTH normal/high - high dose dexa suppresion
- no suppression: small cell lung ca
- suppressed: pituitary adenoma (Cushing’s disease) (MC endogenous)
B. ACTH low
- CT positive: adrenal mass
- CT negative: exogenous (most common)
Dx, Path and Px, and Tx of carcinoid tumors
Dx: neuroendocrine tumor
- 24H urine HIAA or serum chromo A
- chromoA can give false + if on PPI
- Octreotide scan if can’t locate
Path: +chormogranin. desmoplastic mesentery.
- grade ~ Ki67 index
Px:
- Rectum > SI (ileum) > Appendix (MC tumor of appendix)
- GI tract > pulm > GU. Rectum MC GI source
- Carcinoid Synrome: 2/2 liver mets. Flushing, DRH, bronchospasm. R-sided heart failure.
Tx:
- SS analogues (lanreotide) give sx relief
- < 2 cm: local excision (transanal, appendectomy, segmental) ➡ no further w/up. no staging/ppx regimen
- > 2 cm: staging CT. formal cancer resection.
- all lung carcinoids get formal resection with MLND
PPV and NPV
PPV = of those who test + how many have the dz
NPV = of those who test - how many do not have the dz
Increasing prevalence = increase PPV and decrease NPV
Pearson’s R Value
Correlation coeff between -1 and 1
1 = very strong positive (direct proportion)
> .7 = strong positive
0 = no correlation
- .7 = strong negative
Do not determine causation
Phases of clinical trail
- Safety in a small group of humans
- Effectiveness and side effects
- RCT compared to standard of care
- Long term safety and monitoring
Desmoid Tumor - path and tx
A/w FAP (after surgery, 2nd MCCO death), Gardner syndrome
Path- non calcified, fibrotic, low mit index, spindle cells
Tx:
- WLE for extra-abd; NSAID, anti-Estrogen (tamoxifen) if intra!
- XRT if sensitive area
Serologic work-up for adrenocortical mass
- Dexa suppression (cortisol)
- Urine androgens (sex hormones)
- Plasma metanephrines (pheo)
- aldo/rennin ratio > 30 (salts)
MCCO primary hyper-aldosteronism and tx
- Idiopathic bilateral adrenal hyperplasia (60%)- medical
- Adrenal adenoma (Conn’s syndrome)- lap adrenal
- Adrenal adenoca- open adrenal + mitotane
* Can use adrenal vein sampling to distinguish
Respectability of pancreatic tumor and next step
Triple phase CT:
- Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV
- EUS/FNA for tissue dx for neoadjuvant - Borderline- <180 SMA/celiac, reconstructable PV/SMV
- EUS/FNA for tissue dx for neoadjuvant - Resectable
- dx lap (to confirm resectability) + whipple
Paget’s disease of the anus (px and tx)
Px: intractable pruritis, eczematoid rash
Tx: scope (r/o malignancy)
- dc topical agents
- perianal punch bx + WLE
Unresectable cholangiocarcinoma
Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT
PSC screening guidelines
- Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9
- GB CA: US q6-12m
- CRC: colonscopy q1-2 years (regardless of UC)
Colon CA surveillance after curative resection
- Exam and CEA q3-6m x 3 years
- Colonoscopy @ q1, 3, and 5 years
- No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel) - CT CAP q1y x 3 years
Staging w/up of rectal cancer
- TRUS (avoid if > t2) or MRI- T/N stage
- suspicious nodes on MRI count as clinical stage N (neo-adj) - CT CAP- M stage
- C’Scope- for initial dx and sync lesion. not for T stage
- Rigid Sig’Scope- for distance from anal verge (required! even. if c’scope done)
Tx of refractory Crohn’s pan-colitis
- Segmental colitis- partial colectomy
- Rectal sparing pan-colitis- TAC w/ IRA
- Pan-colitis w/ rectum- PC w/ end ileostomy
- IPAA whether w/ or w/out loop should NOT be done on Crohn’s b/c r/o pouchitis
Tx of Lynch Syndrome
- CRC: q1y C-scope @ 20-25; TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma. q1y scope post op (metachronous CA)
- Endometrial: q1y endometrial sampling @ 30-35; ppx TAH-BSO after children
- Ovarian: q1y TVUS and Ca-125 @ 30-35; ppx TAH-BSO after children
- Stomach: EGD/Bx q2-3y @ 30-35
- Renal: q1y UA and US @ 30-35
Polyposis syndromes:
-Muir-Torre
-Gardner
-Turcot
-P/J
-Cowden
-JuP
-Muir-Torre: MLH/MSH; sebaceous gland tumor
-Gardner: APC; desmoid tumors, osteomas, epidermal cysts/lipomas
-Turcot: APC; Malignant CNS tumors
-P/J: STK; myocutameous pigmentation
-Cowden: PTEN; Hamartoma polyps, endometrial/breast/thyroid CA
-JuP: SMAD4; epistaxis, AVM, telangiectasia
Dx and Sx of PNETs
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma
- Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS’oma)
- Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
- Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
- VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
- SSoma: High fasting SS; DM, stones, steatorrhea
*Do not perform imaging or go to the OR until biochemical diagnosis!
Dx and Tx of Pancreatic cysts:
1. Serous cystadenoma
2. MCN
3. IPMN
4. Psuedocyst
-W/up: MRI/MRCP or PP CT ➡ >1.5 cm, sxs, dilated main duct, solid component, fam hx ➡ EUS/FNA
1. Serous cystadenoma: low M/CEA, low Am; resect if sxs
2. MCN: high M/CEA, low Am; resect
3. IPMN: high M/CEA, high Am; resect if main duct or > 3 cm
4. Pseudocyst: low M/CEA, high Am; observe x 6w; if sxs or > 6cm cystgastrostomy
Tx of PNETs:
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma
- Glucagonoma: distal panc w/ splenectomy + cc’y
- Inuslinoma: enucleate
- Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
- VIPoma: distal panc w/ splenectomy + cc’y
- SSoma: resect w/ cc’y
lead vs length time bias
Lead-time bias is due to early detection. Remember the “d” in lead is for early detection.
Length-time bias is due to slow cases being detected more often simply because they are slowly progressing. Remember the “g” in length is for slowly progressing.
Treatment of lung ca
- No N2 disease (stage 1-2) ➡ up-front surgery
- lobectomy + MLNDx. Can consider segmentectomy.
- can wedge if 2:1 margin ratio - N2 disease or T4 ➡ chemo-XRT first
n1- ipsi bronchial/hilar nodes
n2- ipsi mediatinal/subcarinal (2-9)
t1- <3cm
t2- >3cm
t3- >5cm OR invading pleura, chest wall, phrenic n, pericardium OR nodule in same lobe
t4- >7cm OR invading DPGM, mediastinum, heart, great vessels, trachea, RLN, esophagus, vert body, carina. OR different ipsi lobe
Lynch vs FAP Screening
- FAP- chromosomal; APC
- > 100 polyps, including small bowel (duodenum)
- Surveillance: start at 10 - HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
- <10 polyps in the colon
- Surveillance: start at 20
Surgical Tx of thyroid/PT cancers
1. Papillary/Follicular
2. MTC
3. Hurthle
4. Anaplastic
5. PT
- Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk
- MTC: total + bilateral L6 (usually) + T3 post op
- RAI is c/i - Hurthle: lobectomy then total + bilateral L6
- Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
- PT: hemi-thyroid +/- L6 (usually not)
**MRND if L6 is positive
Tx of H/N tumors
- Mucoepidermoid
- Adenoid cystic
- Pleomorphic adenoma
- Warthin/Papillary cystadenoma
- Mucoepidermoid: MC malignant
- total parotid + ppx MRND + XRT - Adenoid cystic: malignant
- total parotid + ppx MRND + XRT - Pleomorphic adenoma: MC benign
- superficial parotidectomy - Warthin/Papillary cystadenoma
- superficial parotidectomy
Transplant ABX ppx
- Bactrim- PCP, toxo gondi, listeria, nocardia
- Diflucan- antifungal
- Valganciclovir- CMV
Transplant cross-matching
- ABO Incompatibility
- A, B, O Ab - Cross-match: recipient serum X donor lymphocytes
- preformed HLA Ab (A, B, DR). DR is most important.
**Livers don’t need a cross-match
**Can give A2 donors to O recipients
**Donor: Ags are important (WBC)
**Recipient: Abs are important
MAC
MAC = minimum alveolar [] to prevent movement in 50% of people
Low MAC = lipid soluble
High MAC = water soluble
- NO has highest MAC
Factors that decrease MAC: older age, met acidosis, hypothermia, anemia, pregnancy
- require less anesthesia
Congenital thoracic disorders - px and tx
1. Pulm sequestration
2. Cystic adenoid malformation
3. Congenital lobar emphysema
4. CDH
- Pulm sequestration: infection w/ abnormal CXR
- tx: resection - Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
- tx: lobectomy - Congenital lobar emphysema: XR looks like tension PTX
- tx: lobectomy - CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
- a/w pulm HTN, NTD, malrotation
- tx: intubate +/- ECMO. Delayed repair.
Wilcoxon test
Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed
- ex: patient satisfaction before and after an intervention (1-5)
COX proportion hazard modeling
Like a regression model but for survival analysis
Allow you to control for different factors
Medical tx for melanoma
- Pd1 inhibitors: pembrozilumab, nivolumab
- CTLA inhibitors: ipilmumab
- If Braf+: braf inhibitor remains 2nd line
Tx of Rhabdomyosarcoma
MC soft tissue tumor in children
tx: surgery + SLNBx
- consider neo-adjuvent if unresectable
- post-op chemo-XRT (very radiosensitive)
HPV precursors in the anus
Low grade: condyloma, AIN1
High grade: AIN2, AIN3 –> should treat
All patients: give HPV vaccine
- High risk pt: homosexual, HIV, women w/ +pap –> screen with anal cytology or anal pap smears
Tx of rectal carcinoid
<1 cm - endoscopic removal
1-2 cm- full thickness excision
> 2cm- LAR or APR
**Invasion into muscularis/LN involvement- require TME
Polypectomy criteria that require formal resection
- Poor differentiation
- Vascular/Lymphatic invasion
- Invasion below the SM
- < 2mm of surgical margin
- Base involvement (Haggit 4)
Cancer screening in FAP
- CRC- q1-2y c’scope starting at 10
- Duo/Stomach ca- EGD at 20 or when polyps occur
- Pap thyroid ca- thyroid U/S q2-5y at 18
- Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
Hormone and production:
- CCK
- Gastrin
- Glucagon
- Histamine
- Insulin
- Motilin
- Secretin
- SS
- CCK: I cell, SI
- Gastrin: G cells, antrum and duo
- Glucagon: alpha cells, pancreas
- Histamine: ECL cells, stomach
- Insulin: beta cells, pancreas
- Motilin: Mo cells, SI
- Secretin: S cells, SI
- SS: delta cells, pancreas
Tx of superficial venous thrombosis
Thrombus is in GSV, SSV
- AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
- No near the jxns ➡ prophylactic AC for 45 days
- Otherwise: surveillance
**Superficial femoral vein is a DEEP vein
**EHIT: heat induced thrombus after RFA
- tx with AC until resolution if it involves femoral jxn and > 50% occlusion
- < 50%: compress, NSAID, surveillance
Sensory nerves of the foot
- Dosal: superfial peroneal n.
- 1st webspace: deep peroneal n. (is deeper)
- Medial: saphenous n.
- Lateral: sural n.
Levels of evidence
1- RCT or SR of RCT
2- Cohort study or SR of cohort studies
3- Case-control or SR of case-control
4- Case series
5- Expert opinion
Polypsos syndromes: px and gene mutations
- MutY
- FAP
- Peutz-Jeghers
- Juvenile polyposis
- Lynch/HNPCC
- Cowden
- MutY: 10 R sided adenomas ➡ MUTYH
- FAP: 100s of adenomas + desmoid ➡ APC
- Peutz-Jeghers: hamartomas + skin lesions ➡ STK11
- Juvenile polyposis: hamartomoas + telangiectasias ➡ SMAD4
- Lynch/HNPCC: L sided adenomas ➡ MLH1, MSH2, MSH6, PMS2
- Cowden: hamartomas + breast/thyroid ➡ PTEN
Tx of dysplasia with IBD (UC and Crohn’s)
- Screening scopes 8 years after onset. Scope q1-3 years thereafter.
- Invisible HGD: confirm w/ high-def endoscopy q3-6m ➡ total proctocolectomy w/ IPAA
- Visible HGD:
1. Resectable: endoscopic resection + serial scopes
2. Not-resectable: TC w/ IPAA - for Crohn’s can do segmental resection
Indications for trx of cholangioca
- cant be intrahepatic (prognosis is too poor)
- must be unresectable, perihilar, < 3cm
- no distant mets
Haggit stage and management
Stage:
0- superficial to MM
1- invasion into head
2- invasion into neck
3- invasion into stalk
4- in SM. superficial to MP.
Mx:
- all sessile are 4 by definition
- 4 is an indication for resection
- < 4 cancer without high risk features ➡ polypectomy alone w/ follow-up scope in 3 months
- otherwise, cancer resection
NCCM CRC screening
- average risk: start at 45. Screen q 10 years.
-1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
Indications for deep inguinal LN dissection for melanoma
- > 4 nodes on superficial dissection
- Positive cloquet’s node
- Enlarged ileo-obturator nodes on CT
- Clinically palpable femoral nodes
Immunotherapy agents and use by target:
- PD-1
- EGFR
- CTLA4
- RET
- Aromatase
- HER2
- PD-1: pembrolizumab; melanoma (1st line); NSC lung ca,
- EGFR: cetuximab; KRAS NEGATIVE colon ca
- CTLA4: ipilimumab; melanoma (2nd option)
- RET: selpercatinib; MTC (MEN)
- Aromatase: anastrazole; ER+ breast ca
- HER2: trastuzumab; HER2+ breast ca
MOA and s/e of trx meds
- MMF
- Basiliximab
- Azathioprine
MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia
Basilixamab: il2 inhibitor
- GI sxs
Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis
WAGR Syndrome - chrom anomaly and px
Chrom: deletion of short arm of chrome 11
Px:
Wilm’s tumor
Aniridia- absent iris
GU anomalies- cryptorchidism, hypospadia, streak ovary
Retardation
Causes of thyrotoxicosis on RAI and tx
- diffuse uptake ➡ Grave’s: BB, PTU, RAI ➡ total/subtotal thyroidectomy if refractory (consider lugol’s solution before surgery)
- focal uptake ➡ toxic adenoma: BB, PTU and lobectomy
- multiple areas of increased uptake ➡ TMN ➡ RAI and/or PTU ➡ total/subtotal thyroidectomy if refractory
Tx/Surveillance after thyroidectomy for cancer
- thyroid lobectomy: thyroid hormone to suppress TSH, get serial U/S to monitor
- total thyroid: monitor thyroglobulin level. thyroid hormone to suppress TSH, get serial U/S to monitor
MOA of abxs: (cell wall, protein, or DNA inhibitor)
- cell wall
- protein 30S
- prostein 50S
- DNA synthesis
MOA of abxs:
- cell wall: PCN, cephalsporin, vanc
- protein 30s: AG (gent), tetracyclines (doxy)
- protein 50s: macrolide (azithro), clinda, linezolid
- dna synthesis: quinolones (gyrase), bactrim (folate), flagyl (free radicals)
