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ABSITE 2023 > High Yield 2023 > Flashcards

High Yield 2023 Flashcards

1
Q

Pheo w/up:

A
  1. Spot plasma or urine metanephrine (sensitive)
  2. 24-urine metanephrine (specific)
  3. CT (> MRI)
  4. MIBG (if suspect multi-focal)
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2
Q

Dx and Localize a gastrinoma

A

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

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3
Q

Order of contents in thoracic outlet

A
  1. Subclavian VEIN
  2. Phrenic NERVE
  3. Anterior scalene MUSCLE
  4. Subclavian ARTERY
  5. Brachial plexus NERVE
  6. Middle scalene MUSCLE
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4
Q

Tx of pancreatitis masses
1. WON sterile
2. WON infected
3. Pseudocyst
4. Infected pseudocyst

A
  1. WON sterile: conservatively
  2. WON infected: step-up approach
  3. Pseudocyst: tx if sxs (infxn, obstruction, pain)
    - 4-6w → internal drain → cyst-enterostomy
  4. Infected pseudocyst: drainage (internal, external, endoscopic). Endoscopic preferred.
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5
Q

Bethesda criteria for thyroid

A

**1 cm is cutoff to get an FNA

  1. Non-diagnostic → repeat FNA
  2. Benign → follow-up
  3. Undetermined significance → repeat FNA or lobectomy
  4. Follicular neoplasm → lobectomy
  5. Suspicious for malignancy → lobectomy vs. thyroidectomy
  6. Malignant → thyroidectomy
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6
Q

Cowden’s mutation and cancers

A

Mutation: pten
Ca: breast, thyroid ca, hamartomas, endometrial

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7
Q

Tx Medullary thyroid cancer

A
  1. TOTAL thyroidectomy
  2. > 1 cm or bilobar: central/level 6 dissection
  3. Lateral neck dissection on that side if central+
  4. Start T4 postop. Monitor w/ calcitonin AND CEA
    - RAI is c/i! (C cell origin)
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8
Q

GCS eye opening

A

4- spon
3- to voice
2- to pain
1- none

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9
Q

Methanol and Ethylene glycol toxicity - Px and Tx

A

Px: profound AG metabolic acidosis
- oxalate stones → renal failure

Tx: NaB + fomipazole (ADH inhibitor)
- consider iHD

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10
Q

Burn degrees

A

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

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11
Q

Dx, Bx, and Tx actinic keratosis

A
  • Dx: red, crusty, weeping lesion
  • Bx: PARTIAL thickness pleomorphism (full = SqCC in Situ)
  • Tx: cryotherapy, photodynamics, imiquimod, cautery (no margin)
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12
Q

Polyps that require surgery instead of endoscopic resection

A
  1. Submucosal invasion > 1mm
  2. Poorly differentiated
  3. <1 mm margin
  4. LV invasion
  5. Tumor budding
  6. Taken piecemeal
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13
Q

T staging indications for neoadjuvant
- eso
- stomach
- colon
- rectal
- lung

A
  • eso: select t1b (SM) or T2 (MP)
  • stomach: t2 (MP)
  • colon: t4b (adjacent organs)
  • rectal: t3 (through MP)
  • lung: n2 nodes
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14
Q

Screening in IBD patients

A
  • 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

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15
Q

W/up of thyroid nodule found on exam or incidental imaging

A
  • 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

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16
Q

Eso dysplasia tx

A
  1. LGD: scope q6-12m
    - OK for fundoplication
  2. HGD: ablation + Q3m scope
    - fundoplication c/i
  3. T1a: ablation
  4. t1b (or low risk T2): upfront esophagectomy

*Fundoplication does not decrease cancer risk

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17
Q

Esophagus blood supply

A
  1. Cervical- inf thyroid
  2. Thoracic- aortic branches (bronchial arteries)
  3. Abd- left gastric/inferior phrenic
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18
Q

TEF - MC types. dx and tx

A
  1. Type MC, 85%
    - Proximal esophageal atresia (blind pouch) and distal TE fistula
    - dx: AXR ➡ distended, gas-filled stomach, coiling tube
    - no UGI needed!
  2. 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

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19
Q

MEN1/MEN2 genes

A

MEN1: MENIN gene, TSGene
MEN2: RET gene, receptor TK protein, proto-oncogene

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20
Q

Birads score

A

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)

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21
Q

MOA, use, s/e of antifungals:
Fluconazole
Voriconazole
Micafungin
Amphotericin

A
  1. Fluconazole: ergosterol synth inhibitor
    - Non-systemic candida (yeast infection, c. albicans)
    - s/e: liver toxic, GI upset
  2. Voriconazole: ergosterol synth inhibitor
    - aspergillosis, C. krusei
    - s/e: visual changes, psychosis
  3. Micafungin: echinocandin; inhibit glucan production
    - invasive/disseminated candidiasis (c. glabrata)
    - s/e: TCPenia
  4. Amphotericin: binds ergosterol and inhibits cell membrane; lipid soluble (brain access)
    - invasive mucor or cryptococcal meningitis
    - s/e: nephrotoxic, hypoK
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22
Q

Recurrent laryngeal nerve + aberrant anatomy

A
  • 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

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23
Q

PFTs for lung resection

A
  1. Preop FEV1 and DLCO predicted > 80% ➡ no further testing
    - >.8L wedge, >1.5L lobe, >2L pneumo
    - < 80% ➡ lung scan for PPO FEV1, DLCO
  2. PPO FEV1, DLCO > 60% ➡ no further testing
    - < 60% ➡ exercise test
  3. VO2 > 10 ml/min/kg ➡ OK for surgery
    - < 10 ➡ high risk for surgery
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24
Q

Cancer associations:
- CEA
- AFP
- CA 19-9
- CA 125
- Beta-HCG
- PSA
- NSE
- BRCA I and II
- Chromogranin A
- Ret oncogene

A
  • 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
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25
Q

W/up and Tx testicular mass:
- Seminoma
- Non-seminomatous

A
  1. PE
  2. Ultrasound
  3. AFP, HCG, LDH
    - Seminoma: no AFP!`
    - Non-seminoma: high AFP, HCG, LDH
  4. Inguinal orchiectomy: any patient with solid testicular mass
  5. 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

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26
Q

Liver collection dx and tx:
1. Pyo
2. Amoebic
3. Echino
4. Fungal

A
  1. Pyogenic: after cholangitis (MC) or div’s;
    - drain and abx (+mica if fungal)
  2. Amoebic: after mexico trip (or aMazon).
    - dx w/ serology/hemagglutination 1st
    - metronidazole (no drain)
  3. Echinococcal: wall Ca+ and sub-cysts
    - albendazole and resect/PAIR
  4. Fungal: 2/2 chemo/neutropenia
    - perc drain + micafungin
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27
Q

Lynch genes and gene funtions

A

Genes:
- MLH1
- MSH2, MSH6
- PMS2
- EPCAM

Fxn:
DNA MM repair gene causing microsatellite instability

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28
Q

Tx of liver lesions:
1. Hemangioma
2. FNH
3. Adenoma

A
  1. Hemangioma: only if sxatic or KM syndrome
    - enucleate (or resect); angioembo if active bleed
  2. FNH: NTD
  3. Adenoma: resect if < 4cm w/out OCP response or > 4 cm, male, or growing
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29
Q

Indications for total thyroidectomy (pap and follicular)

A

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

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30
Q

Von Hippel Lindau - mechanism and surveillance

A

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

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31
Q

Melanoma w/up and tx

A
  1. Punch bx or excisional bx (if small, non-sensitive area)
    - MIS- 5mm margin
    - <1mm- 1cm
    - 1-2mm- 1-2cm
    - >2mm- 2cm
  2. Clinical positive nodes (stage 3) require FNA for confirmation
    - negative: SLNBx
    - positive: completion LN dissection
  3. SLNBx: > 1mm (T2) or if .75-1 mm w/ ulceration or mitotic rate > 1 (T1b)
  4. 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.

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32
Q

PSC vs. PBC - assocaited and tx

A

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

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33
Q

MEN syndromes

A

1- pancreatic (gastrin), pituitary (prolactin), parathyroid (PTH); menin; AD

2a- Parathyroid (PTC),MTC, Pheo (catecholamines); ret; AD

2b- Pheo, MTC, marfanoid/neuroma; ret; AD

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34
Q

Methemoglobinemia - px, dx and tx

A

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)

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35
Q

Tx for DVT

A
  1. unprovoked: malignancy, inherited ➡ indefinite
  2. 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

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36
Q

Dx and Tx Parathyroid ca

A

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)

  1. Parathyroidectomy w/ hemithyroidectomy (+/- L6/central neck dissection +/- XRT)
    - no chemo
    - usually don’t perform any node dissection unless palpable nodes
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37
Q

Mechanism and Tx of thyroid dz:
1. Graves
2. TMN
3. Hashimoto’s
4. DeQuervains/Subacute
5. Reidels

A
  1. Graves: IgG stimulates TSHr ➡ hyperT
    - BB, PTU, RAI ➡ thyroidectomy
  2. TMN: chronic TSH stimulation ➡ hyperT
    - BB, PTU, RAI ➡ total/subtotal thyroidectomy
  3. Hashimoto’s: antiTPO/TG Ab ➡ hypoT
    - thyroxine ➡ partial thyroidectomy
  4. DeQuervains/Subacute: viral URI
    - NSAIDS/ASA ➡ steroids
  5. Reidels: autoimmune inflammation
    - steroid, thyroxine ➡ extensive fibrosis often need surgery for compression
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38
Q

APC gene

A
  • chromosome 5
  • 1st mutn in adenoma to carcinoma
  • mc mutation in colon ca
  • a/w FAP
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39
Q

Carcinoid vs. GIST vs. Desmoid- cells and tx

A
  1. Carcinoid- Kulchinsky cells (enterochromaffin-like)
    tx- < 2cm ➡ appendectomy; > 2cm ➡ R hemi/oncologic resection; chemo if unresectable
  2. GIST- cajal cells
    tx- resection, imantinib
  3. Desmoid- spindle cells
    tx- resect if extra-abdominal. NSAID/estrogen if intra
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40
Q

HLA test

A
  • Tissue typing
  • Donor organ: carries Ag (on WBC)
  • Recipient body: carried Ab

Recipient serum with donor wbc

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41
Q

Tx MEN2A/B

A
  1. urine metanephrine to r/o pheo 1st
  2. tx pheo 1st w/ adrenalectomy
  3. Address thyroid
    - 2A: total thyroid + bilateral central neck by 5y
    - 2B: total thyroid + bilateral central neck by 1y
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42
Q

Tx MEN1

A
  1. HyperPTH 1st w/ 4-gland resection (hyperplasia not adenoma) + thymectomy (remove ectopics)
  2. Asses other lesions
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43
Q

GI Hormone Release and action:
- Glucagon
- Insulin

A

Glucagon: alpha cells of pancreas
- glycogenolysis, gluconeogenesis

Insulin – beta cells of the pancreas
- cellular glucose uptake; promotes protein synthesis

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44
Q

Criteria for transanal excision of adenocarcinoma

A
  1. T0 or T1 (submucosa)
  2. < 3 cm
  3. < 30% circumference
  4. Palpable on DRE (<8cm from anal verge)
  5. No high-risk features (poorly diff, LV invasion)

**local recurrence rate is higher

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45
Q

HNPCC screening and treatment

A
  1. CRC: scope q1-2y starting at 20-25
    - Surgery if:CRC or endoscopically unresectable lesions
    - TAC with IRA w/ q1y rectum surveillance
  2. Endometrial ca
    - childbearing: endometrial sampling q1y
    - after children: TAH-BSO
  3. Ovarian ca: annual pelvic exam and TVUS
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46
Q

Px, Dx, and Tx:

Duo atresia
TEF
Pyloric stenosis
Intussusception
Malro

A

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

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47
Q

Conduit after esophagectomy

A

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)

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48
Q

Tx of High grade AIN/bowen’s disease of anal margin

A
  1. Cryo, curettage, 5-FU, laser
    - Excise if > 3cm, sxatic, atypical w/ 4-6 mm margin
  2. Lifetime surveillance even if tx!
  • Bowen disease = SqCC in situ = high grade AIN
  • Actinic keratosis is precursor

*vs. pagers disease- excision

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49
Q

Types of rejection - px, path, and tx

A
  1. hyper-acute: w/in 1 hour
    - path: ABO Ab (t2 HS)
    - px: mottled organ
    - tx: remove organ
  2. 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
  3. 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)
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50
Q

GI Hormone Release and action:
Gastrin
Somatostatin
CCK
Secretin
VIP

A
  1. Gastrin - G cells in antrum
    - ↑ HCl, IF, and pepsinogen
  2. Somatostatin – D cells in pancreas
    - inhibits gastrin, HCl, insulin, glucagon, secretin, CCK, motilin, pancreatic/biliary/stomach output
  3. CCK – I cells of duodenum
    - gallbladder contraction, relaxation of sphincter of Oddi, ↑ pancreatic enzyme secretion (acinar cells)
  4. 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
  5. VIP – pancreas and gut
    - ↑ intestinal secretion (water and electrolytes) and motility
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51
Q

Stages of graft healing

A
  1. imbibition (direct diffusion)
  2. inosculation (cap beds meet)
  3. revascularization
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52
Q

EBUS accesible nodes:

A

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
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53
Q

Order of cells in healing

A
  1. Hemostasis: PMNs (24-48h)
    - PMNs: remove necrotic tissue, release ROS’s
  2. Inflammatory: monocytes/macrophages (48-96h)
    - mphage: growth factors, angiogenesis, cell proliferation
    - chronic wounds arrest in this stage
  3. Proliferative: fibroblasts (3d+)
    - fblasts: collagen production and secretion
  4. Maturation: fibroblasts (10d)
    - myofibroblasts for wound contraction
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54
Q

Tx for cholangiocarcinoma

A

Tx:
1. Resectable if:
- contralateral hemi-liver with intact HA, PV, and biliary drainage with no tumor
- no distant mets or organ invasion

  1. Consider location
    - Upper ⅓ (Klatskin): lobectomy and stenting of contra lobe
    - Middle ⅓: hepaticojejunostomy
    - Lower ⅓: pancreaticoduodenectomy (Whipple)
  2. Consider chemo + transplant if unresectable
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55
Q

IPMN - dx and tx

A

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

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56
Q

Posterior and anterior vagal trunk branches
Vagotomies

A

Right ➡ Posterior trunk- criminal nerve (post), celiac branch (ant), post laterjet

Left ➡ Anterior trunk- hepatic branch, ant laterjet

  1. Truncal vagotomy: transect ant/post @ distal eso
    - removes lesser curve and pylorus nerve
    - need pyloroplasty. high r/o dumping syndrome
  2. Highly selective: transect @ crow’s ft, preserve laterjet
    - removes innervation to lesser curvature
    - preserves pylorus → no drainage procedure
    - lowest morbidity
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57
Q

Emergent vs. Elective UC Tx

A

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

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58
Q

Peutz-Jeghers - px and screening

A

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

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59
Q

TOS tx

A
  1. neurogenic PT: PT –> rib resection, scalenectomy, BPlex dissection
  2. venous- catheter-directed thrombolysis → surgical decompression
  3. arterial- C7/1r resection, subc artery resection/reconstruction
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60
Q

FAP - Dx and Tx

A

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

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61
Q

BRCA risks and tx

A

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!

62
Q

When to operate on adrenal mass

A
  1. all functioning tumors
  2. all > 6 cm ➡ open resection
  3. if < 6cm with suspicious features - >10HU, <50% @ 10m w/out ➡ open resection

**DO NOT biopsy first

63
Q

Adjuvent chemo for breast ca

A
  1. Adjuvent chemo: tumor > 1cm, nodal dz, triple neg
    - echo before for cardiotox
  2. Tamoxifen/Anastrazole: 5y for HR+ tumors
    - Tamox for men
  3. Trastuzumab- 1y for Her2/neu+ tumors
    - echo before for cardiotox
64
Q

Secretin vs. CCK

A

Both released by duo
S cells ➡ Secretin- duct cells ➡ bicarb
I cells ➡ CCK- acinar cells ➡ enzymes

65
Q

Tx papillary/follicar thyroid can

A
  1. Indications for total thyroidectomy:
    - Tumor > 4cm
    - Distant mets or extra-thyroid disease
    - Poorly differentiated
    - Prior radiation
  2. 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
  3. 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
66
Q

Screening guidelines for breast ca

A

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

67
Q

Reversals:
- BB
- CCB
- Tylenol
- Benzos
- CN/Nitroprusside
- Vecuronium/Rocuronium
- Ethylene glycol
- Methemoglobinemia

A
  • 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
68
Q

Px and tx:
Cryoptococcus
Coccidiomycosis
Histoplasmosis
Mucormycosis

A
  1. Crypto- CNS sxs in AIDs pt
    tx- amphotericin
  2. Coccidio- pulm sxs in the southwest
    tx-amphotericin
  3. Histo- pulm sxs in ohio river valley
    tx- itraconazole → ampho B (only if sxs)
  4. Mucormycosis- burns/trauma w/ bloody cough
    tx- emergent debride, ampho
69
Q

LN harvest/margin
eso
stomach
colon
rectum

A

eso- 15/7cm
stomach- 15/5cm
colon-12/5 cm
rectum- 12/5 cm

70
Q

Cohort study vs. Case control

A

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

71
Q

Li Fraumeni - gene, mechanism, and px

A
  • 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
72
Q

Tumor lysis syndrome - px, path and tx

A

Px: Common 2/2 B cell lymphoma
- hyperU, K, Ph w/ hypoCa

Path: CaPh crystal ➡ renal failure + hypoCa

tx: IV hydration ➡ iHD

73
Q

NNT

A

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

74
Q

Tx childhood GI disease:
- Pyloric stenosis
- Intussusception
- Duo atresia
- TEF
- Malro

A
  • Pyloric stenosis: pyloromyotomy
  • Intussusception: air contrast enema
  • Duo atresia: DD or DJ
  • TEF: right extrapleural thoracotomy
  • Malro: LADDS proc
75
Q

Dx and Tx of GIST

A
  1. 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
  2. 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
76
Q

type 1 vs. type 2 error

A

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”

77
Q

Barrett’s eso surveillance

A

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

78
Q

HNPCC vs. Lynch S
Dx and Screening

A

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

79
Q

GCS motor

A

6- obeys commands
5- localized
4- w/draws
3- flexion (decort) - ‘flex your core’
2- extension (decErebrate)
1- none

80
Q

MCCO healthcare infection:
- HAP/VAP
- central line infection
- SSI
- UTI
- GI infection
- SBP
- Cholangitis
- NSTI
- ICU infection
- Fungal infection
- graft infection

A
  • 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)
81
Q

Tx SqCC of anal canal

A
  • 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

82
Q

T staging for esophageal cancer

A

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

83
Q

MOA and s/e of trx meds
- Tacro
- Cyclosporine
- Sirolimus

A

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

84
Q

Post polypectomy screening

A

-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)

85
Q

Tx papillary/follicar thyroid ca

A

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

86
Q

GCS verbal

A

5- normal
4- confused
3- inappropriate words
2- incomprehensible
1- none

87
Q

Esophageal CA tx

A
  1. HGD, TIS, T1a: endoscopic ablation/resection
  2. T1b: upfront esophagectomy or endo ablation (if low risk)
  3. T2 or N: neoadjuvant then esophagectomy
    - Low grade T2 (< 3cm, no L/V invasion, well diff): upfront eso
  4. T4b or M: definitive chemo-XRT

< 5cm from cricoP: definitive chemo-XRT
> 5 cm from cricoP: esophagectomy

88
Q

Tx of psuedoaneurysm

A

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,

89
Q

Nerve injuries during CEA:
- Recurrent laryngeal
- Marginal mandibular
- Hypoglossal nerve
- G/Ph nerve
- Superior laryngeal
- Accessory

A
  • 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
90
Q

Tx of Complications after Billroth 2:
- Afferent limb obstruction
- Dumping syndrome
- Alk reflux

A
  1. 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
  2. Dumping syndrome: small meals, no sugar –> octreotide
  3. Alkaline reflux gastritis: prevent w/ roux limb > 40 cm.
    - pro-kinetics, bile-acid binding ➡ convert to REY with long roux
91
Q

Primary fuel source in fasting state

A
  1. 1st 4 hours: exogenous glucose
  2. 4h-1d: Liver glycogen
  3. 1d-1w: gluconeogenesis phase (alanine from muscle)
  4. 1w+: protein-sparing phase
    - FA/Ketones are used everywhere
    - RBCs use glucose only
92
Q

Essential fatty acids and immuno-nutrition

A
  1. Linoleic acid- omega-6 (Cis, Unsturated)
    - inflammatory
  2. α-linolenic acid- omega-3 (Cis, Unsturated)
    - anti-inflammatory

Immuno-nutrition = arginine, omega-3 FA
- a/w less infections, shorter LOS

93
Q

BSC vs. SqCC - dx and tx

A

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

94
Q

Dx and Tx of Ewing Sarcoma

A

Dx: “onion skin” in diaphysis
- pelvis is MC location

Tx: chemotherapy (1st line) + surgery or XRT

95
Q

W/up and Causes of low UOP after kidney trx

A

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

96
Q

Dx and Tx:
1. TG duct cyst
2. Brachial cleft cyst
3. Cystic hygroma

A
  1. TG duct: midline through hytoid bone; sistrunk procedure
    - if infected tx w/ abxs first
  2. Brachial cleft: anterior SCM; resection
    - 2nd cleft cyst MC (mid/lower neck)
  3. Cystic hygroma: posterior triangle; resection (avoid infection)
97
Q

Dx and Tx of Addison’s

A

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

98
Q

Px and W/up of Hypercortisolism (Cushing’s syndrome)

A

px: moon facies, striae

  1. Initial tests: choose 1-2
    - 24h urine free cortisol (most se)
    - late night salivary cortisol (when cortisol is lowest)
    - overnight 1 mg dexa suppression
  2. 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)

99
Q

Dx, Path and Px, and Tx of carcinoid tumors

A

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

100
Q

PPV and NPV

A

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

101
Q

Pearson’s R Value

A

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

102
Q

Phases of clinical trail

A
  1. Safety in a small group of humans
  2. Effectiveness and side effects
  3. RCT compared to standard of care
  4. Long term safety and monitoring
103
Q

Desmoid Tumor - path and tx

A

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

104
Q

Serologic work-up for adrenocortical mass

A
  1. Dexa suppression (cortisol)
  2. Urine androgens (sex hormones)
  3. Plasma metanephrines (pheo)
  4. aldo/rennin ratio > 30 (salts)
105
Q

MCCO primary hyper-aldosteronism and tx

A
  1. Idiopathic bilateral adrenal hyperplasia (60%)- medical
  2. Adrenal adenoma (Conn’s syndrome)- lap adrenal
  3. Adrenal adenoca- open adrenal + mitotane
    * Can use adrenal vein sampling to distinguish
106
Q

Respectability of pancreatic tumor and next step

A

Triple phase CT:

  1. Unresectable- distant met, >180 SMA/celiac, any aorta/IVC, unreconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  2. Borderline- <180 SMA/celiac, reconstructable PV/SMV
    - EUS/FNA for tissue dx for neoadjuvant
  3. Resectable
    - dx lap (to confirm resectability) + whipple
107
Q

Paget’s disease of the anus (px and tx)

A

Px: intractable pruritis, eczematoid rash
Tx: scope (r/o malignancy)
- dc topical agents
- perianal punch bx + WLE

108
Q

Unresectable cholangiocarcinoma

A

Criteria
- bilateral HA or PV
- unilateral HA with extensive contra duct
Tx
- no extrahepatic dz ➡ neoadj chemo-XRT + liver trx
- extrahepatic dz ➡ chemo-XRT

109
Q

PSC screening guidelines

A
  1. Cholangioca and HCC: US/MRI/MRCP q6-12m. Annual CA 19-9
  2. GB CA: US q6-12m
  3. CRC: colonscopy q1-2 years (regardless of UC)
110
Q

Colon CA surveillance after curative resection

A
  1. Exam and CEA q3-6m x 3 years
  2. Colonoscopy @ q1, 3, and 5 years
    - No prior scopes: q3-6m (intra-op scope is difficult in un-prepped bowel)
  3. CT CAP q1y x 3 years
111
Q

Staging w/up of rectal cancer

A
  1. TRUS (avoid if > t2) or MRI- T/N stage
    - suspicious nodes on MRI count as clinical stage N (neo-adj)
  2. CT CAP- M stage
  3. C’Scope- for initial dx and sync lesion. not for T stage
  4. Rigid Sig’Scope- for distance from anal verge (required! even. if c’scope done)
112
Q

Tx of refractory Crohn’s pan-colitis

A
  1. Segmental colitis- partial colectomy
  2. Rectal sparing pan-colitis- TAC w/ IRA
  3. 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
113
Q

Tx of Lynch Syndrome

A
  1. CRC: q1y C-scope @ 20-25; TAC w/ IRA or TPC w/ IPAA if CA or unresectable adenoma. q1y scope post op (metachronous CA)
  2. Endometrial: q1y endometrial sampling @ 30-35; ppx TAH-BSO after children
  3. Ovarian: q1y TVUS and Ca-125 @ 30-35; ppx TAH-BSO after children
  4. Stomach: EGD/Bx q2-3y @ 30-35
  5. Renal: q1y UA and US @ 30-35
114
Q

Polyposis syndromes:
-Muir-Torre
-Gardner
-Turcot
-P/J
-Cowden
-JuP

A

-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

115
Q

Dx and Sx of PNETs
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma

A
  1. Glucagonoma: glucagon > 1k; NME, DM, DVT (no stones vs. SS’oma)
  2. Inuslinoma: fasting I/G > .4 and high C-pep; whipple triad
  3. Gastrinoma: G > 1k or increase G w/ sec; refractory PUD, HyperCa 2/2 MEN1
  4. VIPoma: high fasting VIP (exclude other causes); DRH, Achlorhydria, hypoK (2/2 DRH)
  5. SSoma: High fasting SS; DM, stones, steatorrhea

*Do not perform imaging or go to the OR until biochemical diagnosis!

116
Q

Dx and Tx of Pancreatic cysts:
1. Serous cystadenoma
2. MCN
3. IPMN
4. Psuedocyst

A

-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

117
Q

Tx of PNETs:
1. Glucagonoma
2. Inuslinoma
3. Gastrinoma
4. VIPoma
5. SSoma

A
  1. Glucagonoma: distal panc w/ splenectomy + cc’y
  2. Inuslinoma: enucleate
  3. Gastrinoma: enucleate if < 2 cm; >2 cm, whipple
  4. VIPoma: distal panc w/ splenectomy + cc’y
  5. SSoma: resect w/ cc’y
118
Q

lead vs length time bias

A

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.

119
Q

Treatment of lung ca

A
  1. No N2 disease (stage 1-2) ➡ up-front surgery
    - lobectomy + MLNDx. Can consider segmentectomy.
    - can wedge if 2:1 margin ratio
  2. 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

120
Q

Lynch vs FAP Screening

A
  1. FAP- chromosomal; APC
    - > 100 polyps, including small bowel (duodenum)
    - Surveillance: start at 10
  2. HNPCC (Lynch)- microsatalite; MSH, MLH, PMS, EPCAM
    - <10 polyps in the colon
    - Surveillance: start at 20
121
Q

Surgical Tx of thyroid/PT cancers
1. Papillary/Follicular
2. MTC
3. Hurthle
4. Anaplastic
5. PT

A
  1. Papillary/Follicular: lobectomy +/- total + consider ppx L6 for high risk
  2. MTC: total + bilateral L6 (usually) + T3 post op
    - RAI is c/i
  3. Hurthle: lobectomy then total + bilateral L6
  4. Anaplastic: chemo-XRT +/- total if operable + central and lateral nodes
  5. PT: hemi-thyroid +/- L6 (usually not)

**MRND if L6 is positive

122
Q

Tx of H/N tumors

  1. Mucoepidermoid
  2. Adenoid cystic
  3. Pleomorphic adenoma
  4. Warthin/Papillary cystadenoma
A
  1. Mucoepidermoid: MC malignant
    - total parotid + ppx MRND + XRT
  2. Adenoid cystic: malignant
    - total parotid + ppx MRND + XRT
  3. Pleomorphic adenoma: MC benign
    - superficial parotidectomy
  4. Warthin/Papillary cystadenoma
    - superficial parotidectomy
123
Q

Transplant ABX ppx

A
  1. Bactrim- PCP, toxo gondi, listeria, nocardia
  2. Diflucan- antifungal
  3. Valganciclovir- CMV
124
Q

Transplant cross-matching

A
  1. ABO Incompatibility
    - A, B, O Ab
  2. 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

125
Q

MAC

A

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

126
Q

Congenital thoracic disorders - px and tx
1. Pulm sequestration
2. Cystic adenoid malformation
3. Congenital lobar emphysema
4. CDH

A
  1. Pulm sequestration: infection w/ abnormal CXR
    - tx: resection
  2. Cystic adenoid malformation: similar to sequestrion but communications w/ TB tree
    - tx: lobectomy
  3. Congenital lobar emphysema: XR looks like tension PTX
    - tx: lobectomy
  4. CDH: Bochdalek- back/left, MC; Morgagni- rare, anterior
    - a/w pulm HTN, NTD, malrotation
    - tx: intubate +/- ECMO. Delayed repair.
127
Q

Wilcoxon test

A

Compare PAIRED ordinal variables between two groups when normal distribution cannot be assumed
- ex: patient satisfaction before and after an intervention (1-5)

128
Q

COX proportion hazard modeling

A

Like a regression model but for survival analysis
Allow you to control for different factors

129
Q

Medical tx for melanoma

A
  • Pd1 inhibitors: pembrozilumab, nivolumab
  • CTLA inhibitors: ipilmumab
  • If Braf+: braf inhibitor remains 2nd line
130
Q

Tx of Rhabdomyosarcoma

A

MC soft tissue tumor in children
tx: surgery + SLNBx
- consider neo-adjuvent if unresectable
- post-op chemo-XRT (very radiosensitive)

131
Q

HPV precursors in the anus

A

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

132
Q

Tx of rectal carcinoid

A

<1 cm - endoscopic removal
1-2 cm- full thickness excision
> 2cm- LAR or APR

**Invasion into muscularis/LN involvement- require TME

133
Q

Polypectomy criteria that require formal resection

A
  1. Poor differentiation
  2. Vascular/Lymphatic invasion
  3. Invasion below the SM
  4. < 2mm of surgical margin
  5. Base involvement (Haggit 4)
134
Q

Cancer screening in FAP

A
  1. CRC- q1-2y c’scope starting at 10
  2. Duo/Stomach ca- EGD at 20 or when polyps occur
  3. Pap thyroid ca- thyroid U/S q2-5y at 18
  4. Desmoid fibromatosis- CTAP if famhx, palpable mass, or sxs
135
Q

Hormone and production:
- CCK
- Gastrin
- Glucagon
- Histamine
- Insulin
- Motilin
- Secretin
- SS

A
  • 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
136
Q

Tx of superficial venous thrombosis

A

Thrombus is in GSV, SSV

  1. AND w/in 3 cm of Saph-fem jxn or saph-pop jxn ➡ therapeutic AC for 3-6 months
  2. No near the jxns ➡ prophylactic AC for 45 days
  3. 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

137
Q

Sensory nerves of the foot

A
  • Dosal: superfial peroneal n.
  • 1st webspace: deep peroneal n. (is deeper)
  • Medial: saphenous n.
  • Lateral: sural n.
138
Q

Levels of evidence

A

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

139
Q

Polypsos syndromes: px and gene mutations
- MutY
- FAP
- Peutz-Jeghers
- Juvenile polyposis
- Lynch/HNPCC
- Cowden

A
  • 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
140
Q

Tx of dysplasia with IBD (UC and Crohn’s)

A
  • 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
141
Q

Indications for trx of cholangioca

A
  • cant be intrahepatic (prognosis is too poor)
  • must be unresectable, perihilar, < 3cm
  • no distant mets
142
Q

Haggit stage and management

A

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

143
Q

NCCM CRC screening

A
  • average risk: start at 45. Screen q 10 years.
    -1d relative: start at 40 OR 10y b4. Screen q5 years even if normal.
144
Q

Indications for deep inguinal LN dissection for melanoma

A
  1. > 4 nodes on superficial dissection
  2. Positive cloquet’s node
  3. Enlarged ileo-obturator nodes on CT
  4. Clinically palpable femoral nodes
145
Q

Immunotherapy agents and use by target:
- PD-1
- EGFR
- CTLA4
- RET
- Aromatase
- HER2

A
  • 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
146
Q

MOA and s/e of trx meds
- MMF
- Basiliximab
- Azathioprine

A

MMF: purine (T cell) inhibitor
- GI sxs, myelosuppression, anemia

Basilixamab: il2 inhibitor
- GI sxs

Azathioprine: purine (T cell) inhibitor
- myelosuppression, marrow suppression, pulm fibrosis

147
Q

WAGR Syndrome - chrom anomaly and px

A

Chrom: deletion of short arm of chrome 11

Px:
Wilm’s tumor
Aniridia- absent iris
GU anomalies- cryptorchidism, hypospadia, streak ovary
Retardation

148
Q

Causes of thyrotoxicosis on RAI and tx

A
  • 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
149
Q

Tx/Surveillance after thyroidectomy for cancer

A
  • 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
150
Q

MOA of abxs: (cell wall, protein, or DNA inhibitor)
- cell wall
- protein 30S
- prostein 50S
- DNA synthesis

A

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)

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