Surg Onc

Question 1

dx of HCC

Answer 1

quad phase CT scan of the abdomen aka triple phase CT scan (1. unenhanced 2. arterial 3. venous and delayed). HCC will show intense arterial enhancement followed by washout in venous delayed phases.

Question 2

what do you do if you see a liver nodule

Answer 2

1cm: triple phase CT. if not positive, do bx.



Question 3

curative tx for HCC

Answer 3

for Stage 0 (if portal pressure/bilirubin increased), A. liver transplant or radio frequency ablation (RFA)

Question 4

management for stage B HCC

Answer 4

stage B: multi nodular. transarterial embolization (TACE)- this is palliative

Question 5

management for stage C HCC

Answer 5

stage C has portal invasion. Sorafenib (an oral multikinase inhibitor that suppresses tumor cell proliferation and angiogenesis).

Question 6

magament for stage D HCC

Answer 6

sx tx

Question 7

tumor marker for HCC

Answer 7

AFP. Sn= 25-65. not great.

Question 8

what is hepatic resection based on in HCC?

Answer 8

synthetic liver function, tumor involvement in relation to hepatic veins, prognostic variables in Child Pugh classification, platelet count >100

Question 9

milan criteria

Answer 9

basis for selecting patients with cirrhosis or HCC for transplant. need 1 lesions smaller than 5cm or 3 lesions . no vascular or portal involvement.

Question 10

how do you treat localized unresectable HCC

Answer 10

aka stage B (multi nodular). TACE- transarterial chemoembolization. chemo used in TACE is adriamycin. laparoscopic versus percutaneous micro ablation.

Question 11

Role of Rectal EUS vs Pelvic MRI in staging rectal cancer (sensitivities and specificities)

Answer 11

EUS is etter for local T1-T2. MRI is better for T3/T4. MRI is better for circumferential resection margin which is important to assess local recurrence

Question 12

TX for colorectal cancer

Answer 12

T1 and T2: surgical resection. T3N1 (stage 3): neoadjuvant chemotherapy/radiation, followed by surgery, then chemotherapy

Question 13

Surgical treatment for colorectal cancer options

Answer 13

Low Anterior Resection, Abdominoperineal Resection, Laparoscopic versus open sigmoid colon resection/left hemicolectomy, Ileostomy/Colostomy

Question 14

how many LN needed for colorectal cancer resection/staging

Answer 14

12 LN

Question 15

what chemo do you use for colorectal cancer

Answer 15

FOLFOX. contains 1. leucovorin (foilinic acid), 2. fluorouracil, 3.oxaliplatin

Question 16

surveillance of colorectal cancer

Answer 16

colonoscopy and CEA. timing depends on what type of cancer you had?

Question 17

how to stage gastric cancer

Answer 17

CT abdomen/pelvis, CT chest, EUS (endoscopic ultrasound)

Question 18

tx of gastric cancer

Answer 18

chemo for T3 tumors. surgical resection for T1 and T2.

Question 19

D1 versus D2 dissections for gastric cancer

Answer 19

D1: perigastric nodes directly attached along the lesser curvature and greater curvature. D2: add removal of nodes along the left epigastric artery, common hepatic artery, celiac trunk, splenic hilus, splenic artery

Question 20

how many LN needed for gastric cancer resection/staging

Answer 20

at least 15

Question 21

GIST tumors

Answer 21

• From interstitial cells of cajal
• 95% of GIST stain positively for KIT(CD117) mutation
• most common type of sarcoma
• GLEEVEC (imatinib) was originally for CML bcr-abl but now is effective for kit
o Can be used as neoadjucant tx as well as for metastatic and unresectable GIST_ 2 year survival is 75-80%

Question 22

MAGIC trial

Answer 22

• In pts with operable gastric or lower esophageal adenocarcinomas, a periperative regimen of ECF decreased tumor size and stage significantly and improved progression free and overall survival
• Epirubicin, cisplatin, infused fluoruracil

Question 23

Macdonald trial

Answer 23

• Postop chemo should be considered in all pts at high risk for recurrence of adenocarcinoma of the stomach or GE junction
• adjuvant capecitabine plus oxaliplatin versus observation after D2 gastrectomy for patients with stage II or III gastric cancer.

Question 24

CLASSIC trial

Answer 24

5 year follow up from classic trial- still consider adjuvant capecitabine plus oxaliplatin after D2 gastrectomy for pts with stage II or III cancer

Question 25

tumor marker for pancreatic cancer

Answer 25

ca 19.9

Question 26

what chemo can you use for locally advanced pancreatic cancer

Answer 26

5-fluorouracil, gemcitabine (inhibition of DNA synthesis). adding gemcitbaine -> modest improvement in medial overall and 1-year survival compared to 5-fluorouracil (5.7 months versus 4.4 months and 18% versus 2% respectively).

Question 27

what is therapy for metastatic pancreatic cancer

Answer 27

gemcitabine- associated with significant clinical response and better survival. if no clinical response to gemcitabine-> chemordiation using external beam radiation (EBRT) and 5-fluorouracil

Question 28

latest therapy for metastatic pancreatic cancer

Answer 28

folfirinox (5-fluorouracil plus leucovorin, irinotecan, and oxaliplatin). improved overall survival rate compared to those on gemcitabine alone (11.1 vs. 6.8 months respectively

Question 29

dx of pancreatic cyst neoplasms

Answer 29

Pancreas protocol CT, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) with FNA (fine needle aspiration) and fluid analysis of amylase and CEA (carcinoembryonic antigen)

Question 30

5 most common pancreatic cystic lesions

Answer 30

pancreatic pseudocyst, serous cystic neoplasm (SCN), solid pseudopapillary neoplasm (SPN), mucinous cystic neoplasm (MCN), and intraductal mucinous papillary neoplasm (IPMN). *The most important differentiation is between the mucin-producing MCN and IPMN (high risk of cancer, >3 cm require resection) versus the serous SCN and SPN (low risk of cancer).

Question 31

HIPEC definition and indication

Answer 31

Hyperthermic intraperitoneal chemotherapy. Patients with deqbulkable carcinomatosis (widespread cancer throughout the body, even beyond mets): cytoreductive surgery followed by HIPEC can prolong survival and improve symptoms.

Question 32

how is HIPEC done

Answer 32

*After cytoreduction, the abdomen is lavaged with heated (42° C) chemotherapy (typically Mitomycin C) for 90 minutes in the operating room. *Mitomycin C is nephrotoxic, and brisk urine output (>0.5cc/kg/hr) must be strictly maintained overnight after surgery.

Question 33

side effects HIPEC first 10 days

Answer 33

Due to bowel irritation caused by the chemo, all HIPEC patients have a prolonged ileus, lasting 5-10 days post-op. They should remain on sips of clears until flatus, and should be advanced less quickly than other patients. HIPEC patients are also at higher risk for anastomotic leaks.

Question 34

side effects HIPEC >10 days post op

Answer 34

neutropenia post-op. The WBC nadir is typically seen on days 7-10, so a CBC should be checked through this period. Neutropenia (ANC

Question 35

D1 vs D2 for gastric cancer

Answer 35

• After a median follow-up of 15 years, D2 lymphadenectomy is associated with lower locoregional recurrence and gastric-cancer-related death rates than D1 surgery.
• The D2 procedure was also associated with significantly higher postoperative mortality, morbidity, and reoperation rates.
• Because a safer, spleen-preserving D2 resection technique is currently available in high-volume centres, D2 lymphadenectomy is the recommended surgical approach for patients with resectable (curable) gastric cancer.

Question 36

indications for whipple

Answer 36

cancer of head of pancreas, cancer of duodenum, and cancer of the bottom end of bile duct. mets= contraindication

Question 37

intraperiotoneal drainage for trial of pancreaticoduodenectomy

Answer 37

do it! if you avoid it, you’ll increase the freq and severity of complications