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GS Oral Boards > Surg Onc > Flashcards

Surg Onc Flashcards

Screening/follow up

1
Q

Breast Cancer Preoperative Workup

A

Diagnostic mammogram
Core needle biopsy (with ER/PR/Her2 receptor testing)
CXR, LFTs
If +LN or >5cm tumor, add PET CT Chest /Abdomen /Pelvis & MRI brain
If young patient, add MRI breast and BRCA workup
BRCA + pts should all get MRI breast screening

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2
Q

DCIS Treatment

A

DCIS: Lumpectomy* → Adjuvant RT + Endocrine therapy
-Goal 2mm negative margins

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3
Q

Breast: Invasive cancer with negative LN & no chest wall invasion treatment

A

Lumpectomy + SLNB
-If negative SLN → Endocrine therapy + RT
-If + SLN**→ AxLND →Chemo + Endocrine therapy → RT

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4
Q

Breast: Invasive cancer with +LN or chest wall invasion treatment

A

-Neoadj chemo → Lumpectomy/Mastectomy + AxLND → Endocrine therapy + RT

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5
Q

Contraindications to breast conservation therapy

A

If creates poor cosmesis, multicentric disease, T4, prior RT, collagen vascular disease, pregnant (1st or 2nd trimester)

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6
Q

Breast: Indications for adjuvant chemo

A

+LN, >1 cm tumor (although can omit chemo in >1 cm tumor if ER+ & HER2 neg with neg oncotype testing), >5mm tumor if triple negative or HER2+

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7
Q

Indications for RT after mastectomy

A

Invasion of skin/chest wall/pec fascia, ≥4LN+, ≥5cm tumor

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8
Q

Inflammatory breast cancer (dx/tx)

A

Need punch biopsy to diagnose. Then treat like invasive cancer with chest wall invasion (although would need mastectomy not lumpectomy, given extensive skin involvement)

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9
Q

Occult breast cancer (+axillary LN with normal mammogram) [dx/tx]

A

Get MRI breast. If MRI neg, treat like inflammatory breast cancer.

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10
Q

Breast: If HER2+ & >2cm, tx:

A

give neoadjuvant pertuzamab with traztuzamab, then proceed with surgery & RT.

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11
Q

Breast: standard chemo regimen

A

AC followed by T (adriamycin, cyclophos, then taxol)

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12
Q

Breast cancer follow up

A

Q6 month exam
Q12 month mammogram

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13
Q

Thyroid cancer staging

A

TNM staging varies by cancer type and by age
Useful to know that for papillary & follicular carcinoma in patients <45 years old, everything without mets is T1, presence of mets is T2.

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14
Q

Thyroid cancer workup

A

Ultrasound is first step
FNA if >1cm
Check TSH and free T4

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15
Q

Papillary thyroid cancer treatment

A

Total thyroidectomy, (with CLND if clinically +LN on ultrasound or exam) with post op radioactive iodine
If low risk (<45 years old, <1cm nodule, no +LN, no h/o radiation) can consider lobectomy and omit radioactive iodine
Post op levothyroxine for TSH suppression

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16
Q

Follicular thyroid cancer treatment

A

Usually going to present as a thyroid nodule with a FNA that shows a Follicular Neoplasm
Diagnostic thyroid lobectomy first
If final path shows invasive cancer, do completion total thyroidectomy (with CLND if clinically +LN on ultrasound or exam) with post op radioactive iodine.
Can consider stopping at lobectomy if low risk (patient age < 45 years, <1cm in size, no extrathyroidal extension)
Post op levothyroxine for TSH suppression
Hurthle cell variant requires total thyroidectomy and is unresponsive to radioactive iodine

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17
Q

Medullary thyroid cancer treatment

A

Check metanephrine levels to rule out pheo
If + metanephrines, get CT abdomen /pelvis and do adrenalectomy first for pheo
Check PTH & calcium to look for concurrent parathyroid disease which runs with MEN
Preop thyrogobulin and calcitonin levels
All patients get genetics work up
MEN 2A - surgery by age 5
MEN 2B - surgery during first year of life or at time of diagnosis (very rare)
Total thyroidectomy + CLND for all (add modified radical neck dissection if ultrasound shows +LN in the lateral neck)
No radioactive iodine
Follow calcitonin, thyroglobulin and CEA levels to look for recurrence
If post op calcitonin elevated, give external radiation
Auto dominant - screen patient’s children

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18
Q

When is chemo/RT used for thyroid cancer?

A

Only occasionally used for any unresectable, locally invasive or recurrent disease or for mets

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19
Q

Neck lymph node dissection levels

A

I submental, II superior jugular, III mid jugular, IV inferior jugular, V transverse cervical, VI pre/paratracheal, VII behind the sternum

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20
Q

Mod Rad ND

A

all LN tissue from mandible to clavicle, anterior trapezius to lateral sternohyoid, open carotid sheath; spare IJ, CN XII, & SCM

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21
Q

Central LND

A

all LN tissue from carotids laterally, hyoid superiorly, sternal notch inferiorly

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22
Q

Melanoma staging

A

T1: ≤ 1 mm depth
T2: 1.01-2 mm
T3: 2.01-4 mm
T4: >4 mm
N1: 1 LN+
N2: 2-3 LN+
N3: ≥ 4 LN+
a= micromet, b= macromet, c= in transit (>2 cm away) or satellite (<2 cm away but not beyond regional LN basin)
Stage I: <1 mm
Stage II: All ≥1 mm with neg LN
Stage III: any LN+

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23
Q

Melanoma preoperative workup

A

CXR & LDH in all pts
If LN +, get CT Chest /Abdomen /Pelvis, MRI brain, PET, & BRAF testing

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24
Q

Melanoma treatment

A

≤ 0.75 mm depth: WLE (wide local excision)
0.76-4 mm: WLE + SLNB
Clinically + LN: FNA to confirm, then WLE, LN dissection, & INF or ipilimumab

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25
Q

Melanoma WLE margins

A

<1 mm depth: 1cm
1-4 mm: 1-2cm
>4 mm: 2cm

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26
Q

Melanoma recurrence treatment

A

Local excision if possible, otherwise ILP (isolated limb perfusion)
Add radiation if LN + or if extracapsular spread

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27
Q

Melanoma follow up

A

Stage I: q 3-6 month exam
All others: q 3-6 month exam + q 6 month PET CT Chest / Abdomen / Pelvis for 2 years

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28
Q

Lung cancer (non small cell) staging

A

T1: <3 cm
T2: 3-7 cm & ≥ 2 cm from carina, or invades visceral pleura, or main bronchus
T3: >7 cm or <2 cm from carina, invades chest wall, pericardium, or diaphragm
T4: invades mediastinal structures, carina, spine or has tumor in additional ipsilateral (I/L) lobe
N1: I/L bronchopulm or hilar LN
N2: I/L mediastinal or carinal LN
N3: any C/L LN
Stage I: T1 or T2
Stage II: T3N0 or T1,2N1
Stage IIIA: T3N2
Stage IIIB: any T4 or N3

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29
Q

Lung cancer preoperative workup

A

CT Chest / Abdomen + PET
PFTs - need post op FEV >1L (5 lobes, 20% volume each) & DLCO >60%
Stage II or higher need MRI brain
Mediastinal LN evaluation either with mediastinoscopy, CT guided biopsy, EUS or EBUS with biopsy

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30
Q

Lung cancer treatment

A

T1: surgery + LN sample
T2-3 & negative mediastinal LN: surgery + LN sample then chemoRT
N2 or T4 disease: controversial - neoadj chemoRT (cisplatin + etoposide)

31
Q

Lung cancer follow up

A

Q3-6 month exam + CT chest

32
Q

Esophageal cancer (adenocarcinoma) staging

A

T1a: lamina propria or muscularis mucosa
T1b: submucosa
T2: muscularis propria
T3: adventitia
T4: adjacent structures
-T4a: resectable
-T4b: non resectable

33
Q

Esophageal cancer preoperative workup

A

CT Chest/Abdomen, PET, & EUS

34
Q

Esophageal cancer treatment

A

T1a: endoscopic mucosal resection + ablation
T1b: esophagectomy
All others: neoadjuvant chemo/RT (5FU/cisplatin) then possible esophagectomy depending on response.
If +LN post op, add adjuvant chemo/RT if not given preop

35
Q

Esophageal cancer follow up

A

Q 3-6 month exam +/- imaging

36
Q

Gastric cancer staging

A

T1a: lamina propria
T1b: submucosa
T2: muscularis propria
T3: subserosa
T4a: serosa
T4b: adjacent structures
N1: 1-2 LN+
N2: 3-6 LN+
N3: >6 LN+

37
Q

Gastric cancer preoperative workup

A

CT Chest/Abdomen /Pelvis, PET, EUS
If surgical candidate, diagnostic laparoscopy with cytology

38
Q

Gastric cancer treatment

A

T1a: endoscopic resection
T1b: surgery
All others: neoadjuvant chemo +/- RT OR periop chemo (3 cycles preop & 3 cycles postop). Then possible surgery depending on response.
Post op: all except T1 get chemo/RT OR chemo alone (if had preop RT or D2 lymph node dissection)

39
Q

Gastric cancer margins

A

need microscopic negative margins (aim for 4 cm gross margins)

40
Q

Proximal gastric cancer surgery type

A

total gastrectomy + RNY esophago-jejunostomy

41
Q

Mid/distal gastric cancer surgery type

A

distal or subtotal gastrectomy + Billroth I or II

42
Q

Gastric cancer how many lymph nodes

A

16

43
Q

D1 LN dissection (gastric cancer)

A

greater & lesser curve, prepyloric LN

44
Q

D2 LN dissection (gastric cancer)

A

D1 LN & celiac, left gastric, common hepatic and splenic LN

45
Q

Gastric cancer chemo regimen

A

5FU & cisplatin

46
Q

Gastric cancer follow up

A

Q3 month exam
Q6 month +/- CT Chest / Abdomen / Pelvis, +/- EGD

47
Q

Gallbladder cancer staging

A

T1a: lamina propria
T1b: muscularis
T2: perimuscular
T3: serosa, liver, or additional organs
T4: portal vein, hepatic artery, or two additional organs

48
Q

Gallbladder cancer preoperative workup

A

LFTs, CEA, CA 19-9, CT Chest / Abdomen / Pelvis

49
Q

Gallbladder cancer treatment

A

T1a: cholecystectomy alone
T1b-T3: radical cholecystectomy (2 cm liver margins, CBD up to negative margins, lymphadenectomy of hepatoduodenal ligament)
≥ T2 or LN+: add adjuvant chemo/RT

50
Q

Gallbladder wall layers

A

mucosa, lamina propria, muscularis, serosa (no submucosa)

51
Q

Gallbladder cancer chemo regimen

A

gemcitabine/cisplatin

52
Q

Gallbladder cancer follow up

A

Q6 month CT abdomen +/- CEA & CA 19-9

53
Q

Pancreatic cancer staging

A

T1: <2 cm, involving only pancreas
T2: >2 cm, involving only pancreas
T3: extends beyond pancreas, no arterial involvement
T4: celiac artery or SMA involved

54
Q

Pancreatic cancer preoperative workup

A

CA 19-9, CT Chest / Abdomen / Pelvis, ERCP/EUS, staging laparoscopy

55
Q

Pancreatic cancer treatment

A

Neoadjuvant chemoRT (gemcitibine) → surgery → adjuvant chemo
Palliative if arterial involvement or mets

56
Q

Pancreatic cancer when to omit NAC

A

T1 or T2 lesions

57
Q

Obstructive jaundice stent type

A

Metal

58
Q

Obstruction relief surgery for advanced pancreatic cancer

A

Gastrojejunostomy

59
Q

Pancreatic cancer follow up

A

Q 3-6 month exam, CT Abdomen / Pelvis, CA 19-9

60
Q

Colorectal cancer staging

A

T1: submucosa
T2: muscularis propria
T3: peri-colorectal tissues
T4a: visceral peritoneum
T4b: other organs
N1: 1-3 LN+
N2: ≥ 4 LN+
Stage I: T1-2, N0
Stage II: T3-4, N0
Stage III: any LN+

61
Q

Colon cancer preoperative workup

A

CEA, CT Chest / Abd / Pelvis, Colonoscopy

62
Q

Rectal cancer preoperative workup

A

CEA, CT Chest / Abd / Pelvis, Colonoscopy
Add MRI pelvis and EUS

63
Q

Colon cancer treatment

A

Polyp: polypectomy sufficient if >2 mm negative margins, no lymphovascular invasion, & moderate/well differentiated
T1-3, N0: colectomy alone
T4: colectomy +/- adjuvant chemo (FOLFOX)
T4b or LN+: neoadjuvant chemo (FOLFOX) → possible colectomy. If LN thought to be negative preop, but found to be positive post op, add adjuvant chemo.

64
Q

Rectal cancer treatment

A

Polyp: same treatment as colon polyp
T1: transanal excision sufficient if <10 cm from anal verge, <4 cm in size, < ⅓ circumference of rectum, no lymphovascular invasion, moderate/well differentiated.
T2: LAR or APR
T3, T4, or LN+: neoadjuvant chemoRT (FOLFOX) → surgery → adjuvant chemo (FOLFOX). If RT not given preop, add it post op.

65
Q

LN number and margins for colectomy

A

12 LN
5 cm margins (can be 2 cm if needed)

66
Q

Colorectal cancer follow up

A

Q3 month exam, CEA
Q6 month CT Chest / Abdomen / Pelvis
Q1 year colonoscopy (Q3 years once normal colonoscopy)

67
Q

Anal cancer staging

A

T1: <2 cm
T2: 2-5 cm
T3: >5 cm
T4: organ invasion
N1: perirectal LN+
N2: unilateral inguinal or iliac LN+
N3: bilateral inguinal or iliac LN+
Stage I: T1
Stage II: T2 or T3
Stage III: T4 or LN+

68
Q

Anal cancer preoperative workup

A

DRE, inguinal LN exam, gyn exam, anoscopy, CT Chest / Abdomen / Pelvis

69
Q

Anal canal cancer treatment

A

all get Nigro protocol (5FU, mitomycin, RT)

70
Q

Anal margin cancer treatment

A

all get Nigro protocol except for T1 that are well differentiated with no lymphovascular invasion (this gets wide local excision alone with 1 cm margins)

71
Q

Anal cancer: what to do with LN recurrence?

A

inguinal LN dissection

72
Q

Anal cancer: what to do with local recurrence?

A

APR

73
Q

Anal cancer follow up

A

Q3 month exam including LN exam and DRE
Q6 month anoscopy
Q1 year CT Chest / Abdomen / Pelvis

GS Oral Boards (1 decks)

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