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Surg Onc Flashcards

Screening/follow up (73 cards)

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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
Melanoma WLE margins
<1 mm depth: 1cm 1-4 mm: 1-2cm >4 mm: 2cm
26
Melanoma recurrence treatment
Local excision if possible, otherwise ILP (isolated limb perfusion) Add radiation if LN + or if extracapsular spread
27
Melanoma follow up
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
28
Lung cancer (non small cell) staging
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
29
Lung cancer preoperative workup
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
30
Lung cancer treatment
T1: surgery + LN sample T2-3 & negative mediastinal LN: surgery + LN sample then chemoRT N2 or T4 disease: controversial - neoadj chemoRT (cisplatin + etoposide)
31
Lung cancer follow up
Q3-6 month exam + CT chest
32
Esophageal cancer (adenocarcinoma) staging
T1a: lamina propria or muscularis mucosa T1b: submucosa T2: muscularis propria T3: adventitia T4: adjacent structures -T4a: resectable -T4b: non resectable
33
Esophageal cancer preoperative workup
CT Chest/Abdomen, PET, & EUS
34
Esophageal cancer treatment
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
Esophageal cancer follow up
Q 3-6 month exam +/- imaging
36
Gastric cancer staging
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
Gastric cancer preoperative workup
CT Chest/Abdomen /Pelvis, PET, EUS If surgical candidate, diagnostic laparoscopy with cytology
38
Gastric cancer treatment
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
Gastric cancer margins
need microscopic negative margins (aim for 4 cm gross margins)
40
Proximal gastric cancer surgery type
total gastrectomy + RNY esophago-jejunostomy
41
Mid/distal gastric cancer surgery type
distal or subtotal gastrectomy + Billroth I or II
42
Gastric cancer how many lymph nodes
16
43
D1 LN dissection (gastric cancer)
greater & lesser curve, prepyloric LN
44
D2 LN dissection (gastric cancer)
D1 LN & celiac, left gastric, common hepatic and splenic LN
45
Gastric cancer chemo regimen
5FU & cisplatin
46
Gastric cancer follow up
Q3 month exam Q6 month +/- CT Chest / Abdomen / Pelvis, +/- EGD
47
Gallbladder cancer staging
T1a: lamina propria T1b: muscularis T2: perimuscular T3: serosa, liver, or additional organs T4: portal vein, hepatic artery, or two additional organs
48
Gallbladder cancer preoperative workup
LFTs, CEA, CA 19-9, CT Chest / Abdomen / Pelvis
49
Gallbladder cancer treatment
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
Gallbladder wall layers
mucosa, lamina propria, muscularis, serosa (no submucosa)
51
Gallbladder cancer chemo regimen
gemcitabine/cisplatin
52
Gallbladder cancer follow up
Q6 month CT abdomen +/- CEA & CA 19-9
53
Pancreatic cancer staging
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
Pancreatic cancer preoperative workup
CA 19-9, CT Chest / Abdomen / Pelvis, ERCP/EUS, staging laparoscopy
55
Pancreatic cancer treatment
Neoadjuvant chemoRT (gemcitibine) → surgery → adjuvant chemo Palliative if arterial involvement or mets
56
Pancreatic cancer when to omit NAC
T1 or T2 lesions
57
Obstructive jaundice stent type
Metal
58
Obstruction relief surgery for advanced pancreatic cancer
Gastrojejunostomy
59
Pancreatic cancer follow up
Q 3-6 month exam, CT Abdomen / Pelvis, CA 19-9
60
Colorectal cancer staging
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
Colon cancer preoperative workup
CEA, CT Chest / Abd / Pelvis, Colonoscopy
62
Rectal cancer preoperative workup
CEA, CT Chest / Abd / Pelvis, Colonoscopy Add MRI pelvis and EUS
63
Colon cancer treatment
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
Rectal cancer treatment
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
LN number and margins for colectomy
12 LN 5 cm margins (can be 2 cm if needed)
66
Colorectal cancer follow up
Q3 month exam, CEA Q6 month CT Chest / Abdomen / Pelvis Q1 year colonoscopy (Q3 years once normal colonoscopy)
67
Anal cancer staging
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
Anal cancer preoperative workup
DRE, inguinal LN exam, gyn exam, anoscopy, CT Chest / Abdomen / Pelvis
69
Anal canal cancer treatment
all get Nigro protocol (5FU, mitomycin, RT)
70
Anal margin cancer treatment
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
Anal cancer: what to do with LN recurrence?
inguinal LN dissection
72
Anal cancer: what to do with local recurrence?
APR
73
Anal cancer follow up
Q3 month exam including LN exam and DRE Q6 month anoscopy Q1 year CT Chest / Abdomen / Pelvis

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