Surg Onc Flashcards
dx of HCC
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.
what do you do if you see a liver nodule
1cm: triple phase CT. if not positive, do bx.

curative tx for HCC
for Stage 0 (if portal pressure/bilirubin increased), A. liver transplant or radio frequency ablation (RFA)
management for stage B HCC
stage B: multi nodular. transarterial embolization (TACE)- this is palliative
management for stage C HCC
stage C has portal invasion. Sorafenib (an oral multikinase inhibitor that suppresses tumor cell proliferation and angiogenesis).
magament for stage D HCC
sx tx
tumor marker for HCC
AFP. Sn= 25-65. not great.
what is hepatic resection based on in HCC?
synthetic liver function, tumor involvement in relation to hepatic veins, prognostic variables in Child Pugh classification, platelet count >100
milan criteria
basis for selecting patients with cirrhosis or HCC for transplant. need 1 lesions smaller than 5cm or 3 lesions . no vascular or portal involvement.
how do you treat localized unresectable HCC
aka stage B (multi nodular). TACE- transarterial chemoembolization. chemo used in TACE is adriamycin. laparoscopic versus percutaneous micro ablation.
Role of Rectal EUS vs Pelvic MRI in staging rectal cancer (sensitivities and specificities)
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
TX for colorectal cancer
T1 and T2: surgical resection. T3N1 (stage 3): neoadjuvant chemotherapy/radiation, followed by surgery, then chemotherapy
Surgical treatment for colorectal cancer options
Low Anterior Resection, Abdominoperineal Resection, Laparoscopic versus open sigmoid colon resection/left hemicolectomy, Ileostomy/Colostomy
how many LN needed for colorectal cancer resection/staging
12 LN
what chemo do you use for colorectal cancer
FOLFOX. contains 1. leucovorin (foilinic acid), 2. fluorouracil, 3.oxaliplatin
surveillance of colorectal cancer
colonoscopy and CEA. timing depends on what type of cancer you had?
how to stage gastric cancer
CT abdomen/pelvis, CT chest, EUS (endoscopic ultrasound)
tx of gastric cancer
chemo for T3 tumors. surgical resection for T1 and T2.
D1 versus D2 dissections for gastric cancer
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
how many LN needed for gastric cancer resection/staging
at least 15
GIST tumors
• 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%
MAGIC trial
- 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
Macdonald trial
- 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.
CLASSIC trial
5 year follow up from classic trial- still consider adjuvant capecitabine plus oxaliplatin after D2 gastrectomy for pts with stage II or III cancer
tumor marker for pancreatic cancer
ca 19.9
what chemo can you use for locally advanced pancreatic cancer
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).
what is therapy for metastatic pancreatic cancer
gemcitabine- associated with significant clinical response and better survival. if no clinical response to gemcitabine-> chemordiation using external beam radiation (EBRT) and 5-fluorouracil
latest therapy for metastatic pancreatic cancer
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
dx of pancreatic cyst neoplasms
Pancreas protocol CT, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS) with FNA (fine needle aspiration) and fluid analysis of amylase and CEA (carcinoembryonic antigen)
5 most common pancreatic cystic lesions
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).
HIPEC definition and indication
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.
how is HIPEC done
*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.
side effects HIPEC first 10 days
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.
side effects HIPEC >10 days post op
neutropenia post-op. The WBC nadir is typically seen on days 7-10, so a CBC should be checked through this period. Neutropenia (ANC
D1 vs D2 for gastric cancer
- 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.
indications for whipple
cancer of head of pancreas, cancer of duodenum, and cancer of the bottom end of bile duct. mets= contraindication
intraperiotoneal drainage for trial of pancreaticoduodenectomy
do it! if you avoid it, you’ll increase the freq and severity of complications