Misc 6 Flashcards
4 examples of primary malignant bone tumours?
Osteosarcoma
Chondrosarcoma
Ewing’s sarcoma
Multiple myeloma
Give 6 examples of primairy benign bone tumours?
Giant cell tumour Non-ossifying fibroma Simple bone cyst Osteochondroma Enchondroma Fibrous dysplasia
Most common benign bone tumour?
Osteochondroma
Most common non-myeloma malignant bone tumour?
Osteosarcoma
Onions skin appearance on radiograph of bone?
Ewings sarcoma
Investigating bone lesions ?tumour?
Bloods Plain radiography MRI Bone scan CT - staging Consider biopsy
Indications for surgical removal of benign bone tumour?
Rapid growth
Limiting movement or causing severe pain
Impingeing on nearby structures such as nerves or blood vessels
Would you nail IM through a sarcoma prophylactically?
No
Describe the different subtypes of surgical resections?
Intralesional = tumour cut into or entered
Marginal = incision extends into reactive zone surrounding tumour
Wide local = plane of dissection doesnt breach reactive zone
Radical = entire bone/myofascial resection
4 required features for limb salvage surgery? How many do you need?
Bone Nerves Vessels Skin/soft tissue Need at least 2
What are clostridia?
Gram positive anaerobic spore forming rods found in soil, clothing, faeces
4 give clostridia?
Difficile
Botulinum
Perfrinogens
Tetani
System for examining AXRs?
Technical details etc Bowels - small, large and caecum Extraluminal gas Organs - liver, spleen, kidenys, psoas Bones Additional features - catheters, clips etc
4 causes of large bowel obstruction?
Tumours
Strictures e.g. divertuicular
Adhesions
Volvulus
Management of descending colonic tumour causing obstruction?
Left hemicolectomy, +/- defunctioning colostomy or primary anastomosis
Layers of GI tract from internal to external?
Mucosa - epithelium, lamina propria, muscularis mucosa
Submucosa
Muscularis propria
Adventitia/serosa
In order for a GI tract cancer to be malignant what does it have to go through?
Mucosa - musclaris mucosa
What is the adenoma-carcinoma sequence e.g. in FAP?
Normal epithelium mutations leading to hyperproliferation, adenoma formation and eventually carcinoma - such as changes in APC, P53
What is an adenocarcinoma?
Tumour from glandular tissue
Define neoplasm?
Abnormal mass of tissue in which growth is uncoordinated, exceeds that of normal tissue and persists after cessation of stimulus
Surveillance post CRC resection?
CEA monitoring
CT surveillance
Right liver lobes?
5,6,7,8
Left liver lobes?
2,3,4
Differential for hepatomgaly?
Tumour Physiological e.g. pregnancy infective metabolic - alcohol, acromegaly infiltrative e.g. amyloid vascular - budd chiari, heart failure
4 indications for heart transplant?
Advanced heart failure e.g. IHD, dilated cardiomyopathy
Severe ventricular dysfunction secondary to valve disease
Diastolic dysfunction due to restrictive/hyperrophic cardiomyopathy
Heart failure secondary to congential heart disease
Patient criteria for heart transplant?
NYHA class 4, low EF aand less than 1 year to live
Type 1 hypersensitivity and examples?
IgE/Mast cell mediated against antigen
Anaphylaxis
Type 2 hypersnsitivty and examples?
Antibody and completement mediated via MAC
e.g. transfusion reactions, autoimmune haemolytic anaemia, goodpastures, rheumatic heart disease
Type 3 hypersensitivty and examples?
Antibody-antigen immune complex deposition in e.g. kidneys, joints, vessels
e.g. SLE, extrinsic allergic alveolitis
Type 4 hypersensitivity and examples?
Delayed T cell hypersensitivty
e.g. Hashimotos, contact dermatitis, chronic transplant rejection, Mantoux
Mantoux test is an example of which kind of hypersensitivity reaction?
type 4 - delayed T cell
Type 5 hypersensitivty and examples?
Autoantibodies e.g. Graves
Define inflammation and its features?
Body’s stereotypical response to tissue injury - innate and immediate and characterised by heat pain redness swelling and loss of function
Stages of acute inflammation?
Vasoconstriction (white) then vasodilation (red)
Increased vascular permeability
Migration of neutrophils through vessel walls
Phagocytosis
Resolution or progression
4 kinds of chemical mediators of inflammation?
Substances stored and released by cells - histamine, serotonin
Produced by cells in response - interleukins, TNF etc.
Produced in plasma in response - plasmin, bradykinin
Pre-existing cascades - complement, fibrinolytic system, coagulation cascade
What part of the immune system is the complement cascade?
Innate
3 pathways of activation in compleemnt cascade?
Classic
Alternative
Lectin - MBL
5 outcomes from acute inflammation?
Resolution Progrsesion to chronic Organisation and repair - scar Death Abscess formation/supparation
Define chronic inflammation?
Active inflammation, tissue injury and healing all at same time (simultaneous destruction and repair)
What is a granuloma?
Collection of epithelioid macrophages
What is granulomatous inflammation?
Chronic inflammation characterised by epithelioid macrophage that can fuse to form Langerhans giant cells
Classifications of granulomatous inflammation?
Non-caseating e.g. Crohns
Caseating e.g. TB
Immediate, early and late complications of central lines?
Immediate - haematoma, haemorrhage, pneumothorax, haemothorax, arrhythmia, right atrial perf, tamponade, air embolus
Early - Chylothorax, blockage, pseudoaneurysm
Late - catheter fracture, infection, thrombosis, vascular erosion, vascular stenosis
Where do you put IJV central line?
Compressible jugular vein next to incompressible pulsatile carotid, at level of C4 (upper border of thyroid cartilage)
Insert at medial border of SCM aiming towards ipsilateral nipple at 30 degree angle
Describe Seldinger technique?
Needle into vein Guidewire into needle Dilator over guidewire Dilator out Catheter over guidewire Guidewire out
Confirming position of IJV catheter?
Tip should be in SVC just above entry into right atrium
Confirm w US
Transduce pressure to demonstrate venous waveform
CXR
Site of insertion for subclavian line?
Middle of clavicle just underneath aiming towards jugular notch
Things traversed through for subclavian line insertion?
Skin Subcut tissue and fascia Pectoralis major Subclavius muscle Subclavian vein
CVP is a measure of preload, afterload or cardiac output?
Preload
What causes shift in Starling curve to the right/down?
Decreased cardiac motility - e.g. failure, ischaemia
What causes shift in Starling curve to left and up?
Increased cardiac motility - e.g. inotropes or adrenaline
Parts of the CVP trace?
A - wave- atrial contraction
C - wave- bulging of tricuspid into atrium at start of ventricular systole
V - wave - venous return to right atrium
X - descent - atrial relaxation during ventricular systole
Y - descent - opening of tricuspid valve
Which side is presferred for IJV insertion and why?
Right IJV because more straighter and more direct into RA
How to review a non-flushing central line?
Review patient, notes and insertion note
Examine line and ensure no kinking/compression
Cough and breathe deeply as you flush
Anti-thrombolytic flush
Why would you aim to insert chest drain just anterior to mid-axillary line?
To avoid long thoracic nerve of Bell
Differentials for shock in epidural post op patients?
Distributive shock secondary to epidural
Post op hypovolaemia/haemorrhage etc
Intrathecal injection resuling in high spinal
LA toxicity
How are epidural and spinal anaesthetics different?
Epidurals produce nerve root block around the area of insertion e.g. T2-6 at T3/4 blockade
Vs Spinal which acts more like a transection
Why may thoracic epidurals influence haemodynamics and respirationy?
Respiration via intercostal nerves
Haemodynamics via sympathetic blocakde
Where is the thoracic symp innervation to the heart?
T1-5
Pathology of compartment syndrome?
Increased compartment pressure causes increased venous pressure and obstruction of venous return, reducing AV pressure gradient, less capillary tissue perfusion and tissue necrosis
What pressure measurment is suggestive of compartment syndrome?
Difference of 30mmHg or less between diastolic BP and compartment pressure
What is the mechanism of rhabdomyolysis causing renal failure?
ATN - likely toxic myoglobin
Cytological features of malignancy?
Increased number of mitotic figures
Abnormal mitoses
Hyperchromatism - dark nuclei due to DNA concentration
Pleomorphism - varied size/shape of cell + nucleus
Increased nuclear:cytoplasmic ratio
Disadvantages of histology over cytology?
More invasive
More expesnive
Reuquires specialist analysis and takes longer to report
May seed malignant cells
May alter appearance of area for subsequent imaging
Most common benign thyroid tumour?
Follicular adenoma
Which thyroid tumour is most likely to feature haematological metastasis?
Follicular carcinoma
Features of MEN 1?
Pituitary cancer - prolactinoma
Parathyroid hyperplasia
Pancreatic iselt cell tumour e.g. gastrinoma
Featurse of MEN 2A?
Medullay thyroid carcinoma
Phaeochromocytoma
Parathyroid hyperplasia
Features of MEN 2B?
Medullary thyroid cancer
Phaeochromocytoma
Muscosal neuromatosis
Marfanoid body habitus
Define a clot?
Mass formed ffrom constituents of blood, in static blood
What is the difference between a clot and a thrombus?
Clot is formed in stationary blood
Thrombus is formed in flowing blood
Virchows triad contributing to thrombus formtion? Examples of each?
Abnormal blood flow - e.g. AF, stasis (limb or prolonged surgery) aneurysms/stens/valves
Hypercoagulable state- e.g. APLS, Protein C/S def, COCP, trauma, surgery, dehydration, malignancy, Factor V leiden
Endothelial injury e.g. dissection or other vessel wall injury
4 cancers presenting with haematuria?
Renal
Ureter
Bladder
Prostate
Most common type of renal cancer? Alternatives?
RCC - clear cell (most common), papillary, chromophobe)
TCC, medullary carcinoma, carcinoma of collecting ducts are rarer
Features of Von Hippel Lindau?
AD condition Renal cell carcinoma Phaeochromocytoma Pancreatic neuroendocrirne Retinal angioma CNS haemangioblastomas
Management of bladder carcinoma in situ?
Cystoscopy and biopsy +/- TURBT for any visible lesions
Intravesical BCG as its normally diffuse
Radical cystectomy is a surgical intervention
Types of cryptorchidism?
True - maldescended, along usual site of descent e.g. abdominal inguinal or suprascrotal
Ectopic - prepenile, perineal, femoral etc.
Management of post pubertal patient with cryptorchidism and contralateral normal testicle?
Orchidectomy - increased risk of cancer
3 types of testicular tumours and subtpes?
Seminoma and NSGCT
Sex cord stromal tumours e.g. leydig/sertoli
What is a teratoma?
Tumour (neoplasm) consisting of all 3 germ cell layers, able to differentiate into any tissue
What 2 markers do teratomas commonly secrete?
BHCG
AFP
What marker may seminomas secrete? What do they not secrete?
BHCG
Not AFP
How does raised BHCG cause gynaecomastia?
Stimlulates LEydig cells like LH to produce testosterone nd oestrogen
What is a chroiocarcinoma?
Carcinoma producing BHCG
Type of NSGCT in men, or seen in e.g. molar pregnancies in women
Histological features of malignancy?
Loss of normal architecture Invasion of basement membrane Neovascularisation Necrosis Haemorrahge Lymphovascular infiltration Cell shedding
Layers of the scrotum to testicle?
Skin Dartos fascia and muscle External spermatic fascia Cremasteric fascia Internal spermatic fascia Tunica vaginalis Tunica albuginea
Most common site for ectopic ball?
Inguinal canal
Management of neonatal cryptorchidism?
Leave til 6 months to give chance to descend
Then orchidopexy between 6-18 months old if not down by then
Benefits of orchidopexy for cryptorchidism?
Makes detecting cancer easier
Possible lessens risks of cancer and infertility
What kind of testicular tumour may radiotherapy be useful for?
Seminoma
Define metastasis?
Survival and growth of cells at a site distant to their primary origin
Most common kind of melanoma?
Superficial spreading
Most aggressive kind of melanoma?
Nodular
5 types of melanoma?
Superficial spreading Nodular Acral lentiginous Amelanotic Lentigo maligna melanoma
Which type of melanoma is more common in black/asians?
Acral lentiginous
Melanoma resection margin recommendatinos by stage?
0 - 0.5cm
1 - 1cm
2 - 2cm
Different types of wound healing?
Primary - direct opposition
Secondary - left open and not formally closed, by tissue contracction and re-epitheliasition
Tertiary - delayed primary closure
What is Bowen’s disease?
Premalignant condition - SCC in situ, red asymmetrical plaque often seen on legs
What patholgy technique may be useful in melaonma detection vs non-melaonma?
Immunohistochemistry - S-100
3 word definition of DIC?
Pathological consumptive coagulopathy
How much 0.9% saline stays in intravascular compartment?
1/3-1/4
How much dextrose stays in intravascular compartment?
1/9
What is a branchial cyst?
Branchial pouch remnant (failure of involution)
Where are branchial cysts found and how do they present?
Anterior to upper 1/3 of SCM - anterior triangle
Usually present in 2nd-3rd decades as a firm swelling, can get infected
What is suggesitve of branchial cyst on FNA?
Cholesterol rich fluid
Management of branchial cysts?
Conservative
Or surgical if painful, recurrent infection, mass effect or cosmetic
Don’t operate whilst active infection
What causes thyroglossal cyst?
Remnant of thyroglossal duct - embryological descent of thyroid gland from origin at base of tongue through foramen caecum, usually obliterated after this
Are thyroglossal cysts always midline?
No, can be just to side
Also can rapidly enlarge if infected
Differentials for thyroglossal cyst?
Thyroid lesion
Sebaceous cyst
Dermoid cyst
Lymph node
Operation name for thyroglossal cyst excision? What is removed and why?
Sistrunk procedure
Cyst itself and hyoid bone (reduces recurrence rate)
What is seen on histology of thyroglossal cyst?
Lymphoid tissue, occasionally ectopic thyroid tissue
Why is pre-op US and bloods important for thyroglossal cyst?
Ensure there is a normally functioning thyroid - occasionally this contains the only normally functioning thyroid tissue in the body
What is a dermoid cyst?
Benign tumour of mature tissue arising from ectoderm in embryonic development, with squamous keratinising epitheliumc containing skin structures such as hair/sweat glands/teeth
Most common sites for congenital dermoid cyst?
Midline of nose, neck or trunk
Medial and lateral aspect of eyebrows
Why is caution advised in congenital dermoid cyst removal?
May communicate with deeper structures
What is a sebaceous cyst?
Epidermoid or pilar (hair follicle) cysts containing keratin
Management of submandibular abscess?
A-E assessment including airway, floor of mouth Fibreoptic nasendoscopy to assess airway OPG if poss (dentition) IV antibiotics e.g. amox and met OMFS team review
What can submandibular abscess progress to? What is this?
Ludwigs angina
Spreading cellulitis of soft tissues of neck and floor of mouth causing posterior displacement of tongue and potentially airway obstruction
What is a cystic hygroma and where is it normally found? Age?
Congential cystic malformation of lymphatic system
Usually in posterior triangle of neck
Usually found within first 2 years of life
Management options for cystic hygroma?
Aspiration and injection with sclerosing agent
Surgical excision
Where are pharyngeal pouches found? What is it?
Diverticulum through Killian’s dehiscence, which is between the upper and lower portions of the inferior constrictor muscle (between thyropharyngeus and criicopharyngeus)
Demographics of pharyngeal pouch? Presentaiton?
Older men usually
May or may not have neck lump, may gurgle
Regurgitation, hallitosis, weight loss, chronic cough
Ix of choice for pharyngeal pouch?
Barium swallow
Management of pharyngeal pouch?
Conservative
Or endoscopic stapling/external approach excision
General principles for assessing neck lump?
Full ENT exam incl LNs and direct (fibreoptic nasendoscopy) or indirect (mirror) laryngoscopy
FNA or core biopsy, under US guidance if needed
Differentials for neck lump by location?
Superficial - sebaceous cyst, lipoma, abscess
Anterior triangle - branchial cyst, thyroglossal cyst, thyroid swelling, dermoid cyst, submandibular pathology, carotid body tumour, LNs
Posterior triangle - pharyngeal pouch, cystic hygroma, LNs
Within SCM - sternocleidomastoid
Differentials for cervical LNs?
Infectious - dental, tonsils, ENT, face/scalp, cat scratch etc Viral, CMV EBV HIV etc Toxoplasmosis Haemo - lymph/leukamiea Ca - primary/mets Sarcoid
