Pearls

Question 1

1- Mild to Moderate Crohn’s: Induction

2-Mild to Moderate Crohn’s: Remission

3- Moderate to Severe Disease

Answer 1

1- The first-line induction treatment for mild to moderate ileocolonic CD is budesonide, a glucocorticoid. It is typically initiated at 9 mg daily followed by a taper.

Alternative agents for induction include oral glucocorticoids and 5-aminosalicylates (5-ASA). Prednisone 40 mg per day for 7 days, followed by gradual tapering by 5 to 10 mg per week is the typical dose that has proven to have good response. Mesalamine tablets, such as Pentasa or Asacol, are the only 5-ASA agents known to be useful in ileal CD. This class can be used in patients who prefer to avoid steroids or where steroids are contraindicated.

2- For patients who achieved remission with either budesonide or prednisone, it is recommended to taper the drug off completely and follow the patient both clinically and endoscopically. Colonoscopy with evaluation of the terminal ileum should be performed at 6 and 12 months after remission. 5-ASA agents used for induction should be continued for long-term maintenance with similar endoscopic evaluations

3- Patients who cannot be weaned off budesonide or prednisone, who do not respond to treatment above, or have repeated relapse should be considered to have moderate to severe disease. The treatment options for this group include immunomodulators (i.e., azathioprine, 6-mercaptopurine) and biologic therapies (anti–tumor necrosis factor [TNF], monoclonal antibodies).

Question 2

LN bx indications DCIS

Answer 2

Sentinel lymph node biopsy is recommended for women undergoing mastectomy for DCIS

Should consider in women with lesions at higher risk for occult invasive disease:

• clinically palpable lesions
• large lesions (>4 cm on imaging)
• aggressive features including comedonecrosis.

Question 3

Bx options (non palpable mass)

Answer 3

Image-guided percutaneous needle biopsy preferred as the most efficient maneuver.
Mammographically guided (stereotactic) or ultrasound-guided needle biopsy can be performed, depending on which study reveals best images of the target lesion. Core needle biopsies (14 or 16 gauge) have lower false-negative rate compared to cytologic yield from FNA biopsy.
Radiopaque clip must be left in place to document site-sampled breast tissue.
When percutaneous image-guided needle biopsy technology is unavailable, or not feasible (body habitus too large or breast too small; patient unable to tolerate percutaneous procedure), then a follow-up wire localization surgical biopsy is necessary.
When needle biopsy reveals high-risk pathology such as LCIS, atypical ductal hyperplasia, or atypical lobular hyperplasia, then a follow-up wire localization surgical biopsy is necessary to rule out sampling error and coexisting cancer.

Potential Pitfalls

Images of any needle biopsy and/or surgical biopsy specimens are mandatory to confirm inclusion of the target lesion.
If needle biopsy specimen images demonstrate failed/nondiagnostic procedure or discordant findings, then surgical biopsy is necessary.
If surgical diagnostic wire localization specimen images demonstrate a failed procedure, then subsequent management is based upon pathology of any extracted specimen as well as postoperative imaging at a short interval.

Question 4

Specific needle biopsy pathology results that mandate a follow-up surgical resection include the following

Answer 4

1- failed procedures, where the target is not adequately sampled;
2- benign pathologic findings that are radiographically interpreted as being discordant with the target images;
3- “high-risk” pathology, such as lobular carcinoma in situ (LCIS), atypical lobular hyperplasia, and atypical ductal hyperplasia ( 15% to 20% frequency of coexisting cancer- ductal carcinoma in situ and/or invasive cancer) when a follow-up diagnostic surgical wire localization biopsy is performed.

Question 5

IBC chemotherapy

Answer 5

-Neoadjuvant doxorubicin, cyclophosphamide, and paclitaxel (anthracycline + taxane)

Question 6

CTX during pregnancy

Answer 6

• doxorubicin and cyclophosphamide can be given safely neoadj or adj during the second and third trimesters of pregnancy.
• Taxanes safe for post delivery adj tx (paclitaxel, docetaxel)

Question 7

ER+ PR+ CTX target agent

Her2 + CTX target agent

Answer 7

• Tamoxifen

- Trastuzumab/Pertuzumab

Question 8

Preop medical optimization for pheo:
1) option a or b followed by 2)

3) additional control with ….. if 1 and 2 insufficient

Answer 8

1)
a- alpha blockade w/ phenoxybenzamine, a long-acting nonselective alpha antagonist initially dosed at 10 mg per day or twice daily

b- shorter-acting selective alpha1-blockers, such as doxazosin or terazosin, secondary to their avoidance of reflex tachycardia.

2) beta-blocker for reflex tachycardia or tachyarrhythmias.
3) Calcium channel blockers as a third agent for persistent hypertension.

Question 9

Neoadj chemo for Stg II + esophageal cancer

Answer 9

paclitaxel + carboplatin + XRT

Question 10

Melanoma chemo

Answer 10

1 (PD1) inhibitor nivolumab or pembrolizumab is an option for the majority of patients and has been shown to increase recurrence-free survival by ~10% when compared with ipilimumab.

Combination BRAF/MEK inhibitors (dabrafenib plus trametinib) is another option that was shown to improve recurrence-free survival by 19% compared with placebo in patients whose melanoma has a BRAF mutation.

Question 11

Burn resus formula

Burn nutrition formula

Answer 11

4 (% BSA x Weight(Kg))

per day= 25Kcal/Kg + (30Kcal x %BSA)
per day= 1 g/Kg protein + (3g x %BSA)

Question 12

Pancreatic cancer chemo

1) resectable
2) borderline
3) non resectable

Answer 12

Folforinox (5FU, leucovorin, oxaliplatin, irinotican)

Gemcitabine, Abraxane

If resectable: give 3 months pre op chemo followed by 3 months post op +/- radiation post op for positive margins or LNs

If borderline: give 6 months pre op chemo, re-image, if still borderline, XRT then resection

If non resectable, give 6 months pre op chemoXRT for palliation

Question 13

Argatroban

Bivalirudin

Answer 13

Use in HIT patients (Direct thrombin inhibitor)

Direct thrombin inhibitor cleared by kidneys (use in HIT patients with liver failure)

Question 14

sorafenib

Answer 14

chemo for HCC tumor burden to high to treat in child b/c cirrhotic

Question 15

How much future liver remnant (FLR) in normal pt after hepatectomy? in cirrhotic A? when not to resect in cirrhotic A?

Child A
Child B
Child C

Answer 15

25-30%
>40%
if PLT <100K or signs of portal HTN

5-6
7-9
10-15

Albumin (>3.5, <2.8)
Bili (<2, >3)
INR (<1.7, >2.3)
Ascites
Encephalopathy

Question 16

Staging CRC

Answer 16

Stage Grouping

Stage	T	N	M	Dukes	MAC
0	Tis	N0	M0	—	—
I	T1	N0	M0	A	A
T2	N0	M0	A	B1
IIA	T3	N0	M0	B	B2
IIB	T4	N0	M0	B	B3
IIIA	T1, T2	N1	M0	C	C1
IIIB	T3, T4	N1	M0	C	C2/C3
IIIC	Any T	N2	M0	C	C1/C2/C3
IV	Any T	Any N	M1	—	D

Question 17

Mcvay repair

Shouldice repair

Answer 17

Conjoint tendon to coopers ligament with a medial relaxing suture and a lateral transition suture tacked on to the inguinal ligament

1- same steps as lichenstein down to exposure of spermatic cord structures, isolation of hernia sac, high ligation and reduction into peritoneum
2- transection of transversalis fascia from deep ring towards pubic tubercle
3- running non absorbable suture to reapproximate superior and inferior leaves of fascia medial to laterally, then laterally to medially tacking our sutured transversalis fascia to inguinal ligament, then medial to lateral suturing conjoint tendon to inguinal ligament, then run back suture line towards pubis in between previous bites for tension relief (total 4 layer repair)