Surgery + Procedural Interventions Flashcards
What are the primary roles of
surgery/procedures in palliative care?
- Prevent symptoms/negative outcomes
- Relieve symptoms
- Improve QOL
What biochemical measure is a broad predictor of good surgical outcome in PC?
Albumin
What is the primary procedural approach
to managing functional neuroendocrine ca?
RFA (esp. liver lesions)
Which are the 2 most common cancers associated with malignant bowel obstruction?
Colon ca
Ovarian ca
Which patients would benefit from
surgical opinion in MBO?
All
except not within GOC
except prognosis <days to short weeks
What are 5 contraindications to surgical
intervention in MBO?
- Multilevel obstruction
- Palpable abdominal mass(es)
- Peritoneal carcinomatosis
- Poor function (not quantified)
- Short prognosis
- Ascites (relative)
What is the success rate of stenting for
reachable MBOs?
> 70%, higher in colorectal
What are the 3 most common
complications of endoscopic stenting?
- Perforation
- Stent migration
- Stent occlusion
What procedure is available for
fungating breast wounds?
“Toilet” (i.e. hygiene) mastectomy
total chest wall debridement and reconstruction
Which 3 cancers are most likely to cause
malignant skin issues?
- Primary skin ca (obviously)
- Breast
- Soft-tissue sarcoma
List 3 surgical methods of bypassing
the biliary tract (i.e. not ERCP)
- Choledochojejunostomy
- Choledochoduodenotomy
- Cholecystojejunostomy
i.e. drain liver into bowel
Which is superior for GOO–stent or surgery?
Stenting (10% failure)
vs.
Surgery (40-90% failure)
Which is superior for biliary tract obstruction?
Stenting
What is the infection risk with abdominal PleurX insertion?
20-30%
Which dangerous procedure is rarely done
for refractory ascites?
Peritoneovenous shunting
What is the cutoff prognosis for
splenectomy vs. radiation in heme malig.?
> 6mo, do surgery
2* increased recurrence risk w. radiation
Is bony pain inflammatory or neuropathic?
Neither–different marker profile
What features of physical exam are essential in the patient with bony mets and back pain?
NEUROLOGICAL EXAM
SLR
deep tendon reflexes
strength testing
Which bony changes must be present for a
metastasis to appear on X-ray?
50% medulla loss
30% cortical loss
What are the 2 (3ish) types of bony mets?
Sclerotic (osteoblastic)
Lytic (osteoclastic)
Mixed
Which cancer is most associated with
sclerotic bony mets?
Prostate
Which cancers are ass’d with lytic bony mets?
Lung
Renal
Thyroid
Myeloma
What is the sensitivity of a bone scan?
80%
Which bony lesions tend not to
appear on bone scan?
Highly aggressive mets (lung, melanoma)
Mets that are not healing (myeloma)
PET vs. bone scan for which bony mets?
PET–lytic (95% sens.)
bone scan–sclerotic (100% sens.)
Which patients with impending/actual pathological #s should be referred to ortho?
All except the extremely ill
What is the median prognosis for a patient
with bony metastases?
8 months
higher in breast, thyroid
lower in lung
What is another common cause of fracture in malignancy, other than pathological?
Osteoporosis
- androgen deprivation therapy
- older patients
What are the 4 features of the Mirels score to predict pathological # risk?
- Pain
- Site
- Blastic vs. lytic
- Proportion of cortex involved
How is the Mirels score calculated?
Each item is scored 1-3
Pain (mild, moderate, impairing function)
Site (UL, LL, trochanteric)
Cortex (<⅓, ⅓-⅔, >⅔)
Type (blastic, mixed, lytic)
Which 2 components provide most
of a bone’s strength?
Calcium hydroxyapatite (compression)
Collagen (tension)
What forces is bone weakest to?
Shear
Torsion
How do small bony mets increase # risk?
Small surface defects
→ disproportionate drop in shear strength
20% of bone diameter → 60% drop
>50% → 90% drop
Most common limb site of pathological #
Proximal femur
(90% of femur #, 60% of limb #)
What is the weakest form of bony fixation?
Plate fixation with screws
Which ortho option is most successful?
Hemi- or total arthroplasty
How should epiphyseal # be managed?
Arthroplasty
How should diaphyseal # be managed?
Intramedullary fixation
What is the hardest location to fix
an appendicular bone?
Metaphysis 2* many tendon attachments
What force causes the majority of humeral #?
Torsion
Are metallic or plastic stents more
successful for biliary obstruction?
Metal–90% vs. 70%
What function loss is expect with both shoulder and elbow surgery for #?
Reduced abduction/overhead
Reduced extension
What is the advantage of a plastic stent?
It can be replaced
metal stents must be stented over
What did plastic-coated metal stents for
esophageal obstruction replace?
Rigid plastic tubes inserted under GA
What are 4 reasons to embolise in palliative care settings?
- Hemostasis
- Analgesia
- Tumour shrinkage
- Reduce hormone release from func. ca
What is the risk of embolising
hormone-secreting tumours?
++ hormone release in short term
consider prophylactically treating
(e.g. phenoxybenzamine)
Which organ is especially appropriate for tumour embolisation?
Liver, esp. HCC
In which liver population should you avoid arterial embolisation?
Cirrhosis–consider direct tumour lysis instead
What is the post-embolisation syndrome?
- Fever
- Increased pain
- WBCs
- Malaise
- reflects tumour necrosis
- if longer than a few days, consider infx
- if CRP markedly elevated, consider infx
What is the rate of vertebroplasty complication in malignant disease?
<10%
What are the risks of vertebroplasty?
- Spinal cord damage
- Bleeding at injection site
- Allergic reaction
- Infection
What are the three forms of tissue ablation?
- Heat (laser, RFA, U/S, etc.)
- Cold (liquid N2)
- Chemical (EtOH, acetic acid)
What are the limitations of EtOH ablation?
Can only diffuse c. 3cm, so no bigger tumours unless you inject multiple sessions
Which technique is the main option for ablation?
Radiofrequency
(i.e. heat)
What features of a renal cell ca would make it more appropriate for RFA?
- Small tumour
- Peripheral location
- Poor surgical candidate
