misc Flashcards
Most common complication of a bone marrow biopsy
retroperitoneal hemorrhage; fatalities have been reported
technique for bone marrow biopsy
lateral angle towards the ipsilateral ASIS
avoid hitting the retroperitoneal vessels
Do you have to biopsy liver mets to establish a diagnosis of CRC?
No; CEA level and radiolgy are acceptable
treatment of pseudoaneurysm with pancreatic pseudocyst
need IR embolization first;
pseudoaneurysm is contraindication to an IR drain.
most common presentation of nasopharyngeal caner
painless neck mass
Three steps for missing parathyroid during 4 gland dissection
- resect thymus.
- divide middle thyroid vein to mobilization thyroid to expose the esophagus and trachea.
- Thyroid lobectomy is the last step before aborting
When should you perform median sternotomy for an ectopic parathyroid?
Should basically never happen; Would need clear imaging showing an intrathoracic gland preop.
Specific mutations for MEN 2a
RET exons 10, 11, 13, 14
Specific mutation for MEN 2b
RET codon 918
What is the most likely diagnosis in a thyroid nodule for <14 year old?
50% of thyroid nodules are malignant in children under 14 years
most common cancer still is papillary.
risk of cancer is highest in the young and old.
most common complication of percutaneous cholecystostomy:
Bile leak during placement or removal of the tube occurs in approximately 3% of patients. Many leaks are self-limited.
serum markers for medullary thyroid cancer
Carcinoembryonic antigen and calcitonin
Mucinous Cystic Neoplasms - pathology finding:
ovarian-type stroma (resect them all)
cholesterol polyp in a gallbladder - ultrasound features
pedunculated
hyperechoic
do not have posterior shadowing
initial management of hypercalcemia from bone metastasis
bisphosphonates and calcitonin
PTU mechanism
interferes with the uptake of iodine by the thyroid and preventing coupling of iodotyrosines that combine to produce thyroid hormone.
Feared side effect of PTU
agranulocytosis occurs in 0.1% to 0.04% of patients.
mechanism of lithium for management of hyperthyroid
reduces synthesis of thyroid hormone and blocks its release.
Adrenal operation if patient has had a previous contralateral adrenalectomy? (MEN2a/Pheo)
a partial (cortical-sparing) adrenalectomy (don't do if malignant tumor)
The virus associated with nasopharyngeal carcinoma and Burkitt`s lymphoma is:
Epstein Barr Virus
What other virus may play a role in Burkitts lymphoma in addition to Epstein Barr Virus?
Malaria
Burkitt’s Lymphoma in the US is most commonly associated with:
HIV
How do you perform a secretin stimulation test for ZE syndrome?
baseline gastrin level is drawn
2u/kg of secretin given iv
gastrin levels are drawn at q 5 minutes x6
increase in gastrin of more than 200pg/ml above the basal level supports the diagnosis of a gastrinoma.
A patient is undergoing distal, subtotal gastrectomy with D2 lymphadenectomy for gastric cancer. Preservation of which artery is required to assure adequate perfusion of the gastric remnant?
Left gastroepiploic
mechanisms of PTH
PTH has direct effects on skeletal muscle and the kidney with indirect effects on the gastrointestinal tract. PTH causes increase reabsorption of calcium by the kidney and inhibits the reabsorption of phosphate. PTH stimulates the hydroxylation of 25-hydroxy vitamin D and secretion of bicarbonate.
risks of rectal cancer with FAP
Patients who undergo total abdominal colectomy with ileorectal anastomosis have the risk for developing rectal cancer which has been shown to be 4%, 5.6%, 7.9%, and 25% at 5, 10, 15, and 20 years after resection.
cell of origin for MTC
calcitonin secreting para-follicular cells, or C-cells.
metabolic derangement from obstructive jaundice
Vitamin K deficiency
Biliary obstruction prevents intestinal formation of micelles necessary for absorption of the fat soluble vitamins A, D, E, and K.
what medicine has been studied with RCTs for malignant bowel obstruction?
octreotide
[find citations]
pseudohypoparathyroidism, definitions
Pseudohypoparathyroidism is characterized by target tissue resistance to parathyroid hormone (PTH), low serum calcium, elevated serum phosphate, and defect in skeletal growth and development.
pseudohypoparathyroidism, mutation
This is a rare familial disorder due to mutations in the GNAS1 gene.
pseudohypoparathyroidism mechanism
parathyroid hormone function itself is normal, but the kidney cannot respond to PTH stimulation. This results in hypocalcemia and hyperphosphatemia
What colostomy to perform if patient needs/getting RT?
End is preferred over a loop. Radiation may lead to contraction of the distal limb and disrupt the ostomy.
Most common cause of gastric outlet obstruction?
adenocarcinoma;
PUD is now rare.
What surveilance is needed after Ileoanal anastomosis for FAP?
anoscopy and upper endoscopy
Gastrinoma Triangle
. The gastrinoma triangle includes the area to the right of the superior mesenteric vessels (cystic and common bile ducts), in the head of the pancreas, or in the duodenal wall (2nd and 3rd portions of duodenum)
Percentage of gastrinomas that are associated with MEN-1
25%
What is adjuvant therapy for MALT lymphoma?
none required if localized disease completely excised.
Yuman Fong factors for CRC live metastasectomy prognosis?
a node positive primary disease-free interval of less than 1 year increasing number of metastasis largest metastasis greater than 5 cm serum CEA > 200.
Patients with all factors favorable -> five-year survival of 60%
How do you tell FNH from adenoma on liver sulfur colloid scan?
Unlike focal nodular hyperplasia, hepatic adenomas do not contain Kupffer cells and will appear cold on a sulfur colloid liver scan
Size cutoff to attempt discontinuation of OCPs for a hepatic adenoma
4 cm
The most common cause of primary adrenal insufficiency is:
autoimmune disease
How do you do a high dose dexamethosone suppression test?
2mg of dexamethasone is given orally q6 hours for two days. During this time, urine cortisol level is measured on the second day
dexamethosone supression result for a pituitary adenoma
urine free cortisol level should decrease by at least 50%. ACTH levels will also be suppressed in a pituitary adenoma by the end of the 2 days
dexamethosone result for ectopic ACTH secreting tumor
the high-dose dexamaethasone test will not cause a suppression of the ACTH nor urine free cortisol level.
formal test to diagnose exocrine pancreatic insuffieciency
> 20 g of fecal fat on a 24 hour stool collection
The three most common screening tests for cortisol overproduction are:
The three most common screening tests for cortisol overproduction are: 24-hour urinary free cortisol, low-dose dexamethasone suppression test, and late-night salivary cortisol.
Hounsfield unit cutoffs for adrenal tumors
An adrenal mass with HU of < 10 on noncontrast CT is 100% specific for a benign tumor. For tumors with a higher HU contrast washout of < 50% after 10 minutes is suspicious for malignancy. Other suspicious imaging features include tumor size > 4 cm, irregular borders, inhomogeneity and calcifications.
Cowden syndrome
Breast cancer
intestinal polyps
facial trichilemmomas, mucosal papillomas, and acral keratoses.
Frequency of Supernumerary parathyroid glands
five or more glands in ~13%,
only three parathyroids in ~3%.
Which locations results in the worst long-term functional outcome after curative operation and radiation therapy for squamous cell carcinoma of the oral cavity?
base of tongue
which sarcoma’s spread via lymphatics?
rhabdomyosarcoma,
epitheloid sarcoma,
clear cell sarcoma,
synovial sarcoma and vascular sarcoma.
criteria to diagnose a parathyroid carcinoma?
Marked mitotic activity
dense fibrous stroma
evidence of local invasion into the capsule or surrounding vessels
What is treatment for thyroid lymphoma?
excellent responses to CHOP unless significant compressive symptoms are present.
For diffuse large B-cell lymphoma, the therapy is CHOP (Cytoxan®, hydroxy doxorubicin, Oncovin®, Prednisone) followed by radiation.
Locations of apocrine sweat gland tumors
These glands are found primarily in the axillae, groin, and perineum
Neoplasms arising from eccrine glands are most commonly found
Neoplasms arising from eccrine glands are most commonly found on the palms of the hands and soles of the feet
trials for oncotype DX
NSABP B-14
NSABP B-20
TAILORx trial
Randomized mid-risk oncotype breast cancer patients to chemoendocrine therapy v endocrine therapy alone.
No chemo benefit for ER+PR+H2-, node–negative breast cancer who had a midrange 21-gene recurrence score
What do you do with a cystic duct margin that is positive for gallbladder cancer?
In the setting of a cystic duct margin that is positive, a bile duct resection with reconstruction is an appropriate operation.
What to do with a 2 cm solitary thyroid nodule in a 65 year old man?
Can go straight to excision for solitary nodule in man >60 years.
At colonoscopy for rectal bleeding, a 45-year-old man has a 1.0-cm submucosal lesion of the rectum. The biopsy diagnosis is granular cell myoblastoma. Pathologic examination of the specimen demonstrates positive margins. Appropriate management would be:
These are benign tumors, with fewer than 2% exhibiting malignant morphology. Thus, for colorectal lesions, colonoscopic excision is the procedure of choice.
Segmental colectomy is needed for malignant polyps with the following characteristics:
lymphovascular invasion poor differentiation less than 2mm margin piecemeal polypectomy invasion of the lower third of the submucosa central depression or ulceration.
PTU efficacy
Treatment with PTU has a 30% remission rate of hyperthyroidism at 18 months.
Management of thyroid FNA
“atypia of undetermined significance” (AUS)
“follicular lesion of undetermined significance” (FLUS)
In patients where malignancy risk is low, repeat FNA can be done. In patients with risk factors for malignancy (age >50, family history of thyroid cancer, personal history of irradiation, etc.), an aggressive approach to diagnosis is warranted
“book” cutoff value to start oral calcium supplementation after parathyroidectomy
> = 7.5 mg/dL
Colonoscopy scheduling
If a patient has a first-degree relative with colorectal cancer or polyps before age 60, or 2 first-degree relatives with colon cancer and/or polyps at any age, the patient should have screening colonoscopy starting at age 40, or 10 years before the earliest diagnosed family member, with subsequent colonoscopies every 5 years. If the patient has a first-degree relative with colorectal cancer or polyps at age 60 or older, or 2 second-degree relatives at any age, screening colonoscopy should be at 40 (or 10 years prior to earliest diagnosed family member), with subsequent colonoscopies at 10 year intervals. Patients with one second-degree or third-degree family member are considered average risk, and should have screening at age 50, at 10 year intervals (same recommendations for patients with no family history). Patients with known HNPCC should undergo their first screening colonoscopy at age 20-25 years (or 10 years prior to the earliest diagnosed family member), with subsequent colonoscopies every 1-2 years. In all scenarios, the time interval of subsequent colonoscopies may be shortened depending on the findings at the prior procedure.
dimensions on thyroid ultrasound that are concerning for malignancy.
Generally, dimensions that are “taller than they are wide” are suspicious for cancer. Benign lesions tend to grow more radially (outward) while cancers typically grow more vertically. If the cancer grows quickly, it can “mushroom” up from the thyroid surface, giving it an irregular appearance.
Worst pathological feature for a DFSP?
fibrosarcomatous change
Factors that predict MALT lymphoma treatment failure after H. pylori eradication alone:
transmural tumor extension
nodal involvement
transformation into a large cell phenotype
t(11;18) or nuclear BCL-10 expression.
The most common mutation in pancreatic cancer is:
kras
When do you perform segmental duodenectomy for adenocarcinoma?
For lesions amenable to segmental resection, segmental duodenal resection with regional lymphadenopathy is the procedure of choice.
Pancreaticoduodenectomy is reserved for those patients with lesions in the first and second portion of the duodenum.
