High-Yield and Frequently Missed ABSITE questions

Breast: LCIS -- who primarily gets this, what is most important characteristic, what % get cancer, where, and what type?

- pre-menopausal - NOT premalignant itself - 30% lifetime risk 70% ductal CA

Parathyroid: what is Rx for 4 gland parathyroid hyperplasia (2)?

1) 4 gland resection and forearm re-implant 2) 3.5 gland resection

Colorectal: how is decision made for APR vs LAR?

2cm distal margin in rectal cancer, if can't be achieved then need APR instead of LAR

Breast: LCIS -- what % have synchronous cancer?

5%

Breast: when is SNLB indicated (size, nodes, tumor status, metastatic risk)>?

>1 cm, no positive nodes (obviously), primary tumor present, low risk of axillary mets,

Parathyroid: what is an initial treatment for hypercalcemia?

Hydration with saline and diuretics is initial strategy for hypercalcemia from any cause

Thyroid: what is Plummer's syndrome, and what is done for it?

Hyperthyroidism secondary to an autonomously functioning thyroid nodule (Plummer's syndrome) is best tx with surgery and not RAI

Biliary: what is treatment for gallbladder CA based on presentation (2 major options)?

If T1a (confined only to lamina propria) cholecystecotmy; anything else, then skeletonize area, plus wedge segment 4/5 liver and regional nodes, consider CBD if cystic duct involved

Colorectal: what is treatment for anal squamous carcinoma?

Nigro -- chemo (5-FU/mitomycin) + radiation; surgery reserved for failures

Colorectal: when is chemo/RT done before surgery, when not, in colon CA, based on T and N?

T 3-4 or N+ get chemo/rad, T1-2 managed by surgery primarily

Colorectal: how many levels in colon CA T staging, and what is each?

T1) mucosa/submucosa T2) into muscularis propria T3) through muscularis propria T4) into other organs/structures

Thyroid: what symptom does injury of superior laryngeal nerve cause?

weak voice, fatigue of voice at higher ranges

Spleen: if there is a very low platelet count and there is ITP, and splenectomy is needed, when should platelets be transfused, what is one exception?

when splenic artery is ligated, except if there is preop bleeding, then at time of incision

Biliary: what is treatment for types of choledochal cyst (1-5)?

all need resection with CCY / CBD removal, RNY hepaticojejunostomy, 4+5 need hepatectomy vs. transplant if diffuse

Liver: what are 2 primary routes for pyogenic liver abscess, and what are 2 specific causes for each?

biliary infection (cholecystitis/cholangitis) - most common seeding from portal vein drainage (appendicitis, diverticulitis)

Esophagus: what should be suspected if patient has chest pain/fever/resp distress after emesis resulting from large meal?

boerhave's syndrome

Thyroid: what is superior laryngeal nerve a branch of, and what does it divide into?

branch of vagus, divides into internal/external

Colorectal: coloncyte fuel, and derived from where?

butyric acid, from bacterial fermentation

Thyroid: for Hurthle/follicular, what is done if carcinoma identified on permanent section?"

completion lobectomy

Parathyroid: what 2 signs are suspicious for parathyroid carcinoma?

diagnosis of parathyroid carcinoma is suspected with: 1) very high calcium (>15mg/dl); 2) palpable neck mass in the setting of primary hyperPTH

Esophagus: what is treatment for barrett's esophagus and high grade dysplasia?

esophagectomy

Breast: what is treatment for DCIS in male/female?

female -- BCT + xrt OR mastectomy; male -- mastectomy

Liver: amebic abscess - what are 3 presenting symptoms?

fever, RUQ pain, RUQ tenderness

Liver: amebic abscess - what is first line treatment, when should surgery be done, and what other option exists?

first option metronidazole -- surgery or percutaneous drainage if failure

Colorectal: MALT tumor (lymphoma) - when is surgery first line treatment?

gastric outlet obstruction

Small Bowel - what is general treatment (after failed medical management) for duodenal obstruction on Crohn's, and why?

gastrojejunostomy -- stricturoplasty is difficult, and resection needs Whipple; may do duodenojejunostopy if distal stricture

Thyroid: what is preparation for I-131 scan?

have to be hypothyroid for the scan -- need to stop thyroid hormone before scan (6 weeks for synthroid, 3 weeks for cytomel)

Breast: what do you do if you can't find radiotracer dye in SNLB?

have to do formal ALND

Liver: amebic abscess - what test may help diagnose?

indirect hemagglutination

Liver: echinococcal abscess - what is diagnosis (2)?

indirect hemagglutination / ELISA

Liver: why is focal nodular hyperplasia hot on liver scan?

intact kupffer cells

Parathyroid: for parathyroid carcinoma, what are surgical findings compared to adenoma?

invade surrounding structures as opposed to parathyroid adenoma that "shell out"

Liver: how would segment 1+2 be resected?

left hepatic lobectomy

Parathyroid: what cancer is most likely to cause paraneoplastic hypercalcemia, how is this distinguished from primary hyperparathyroidism, and what is the treatment?

paraneoplastic PTH-like peptide typically from small cell lung cancer -- most commonly has normal/decreased PTH -- treated with osteoclast inhibitor (bisphosponate)

Parathyroid: what is treatment for parathyroid carcinoma?

parthyroidectomy + ipsilateral thyroid lobectomy

Spleen: what are varices with splenic vein thrombosis usually associated with?

pancreatitis (acute)

Liver: in what population should giant liver hemangioma be resected, how can it present in this population (name of syndrome and its 2 problems, other possible problem)?

pediatric population -- kasabach-merit syndrome = hepatic sequestration and thrombocytopenia, also can present with AV shunting and heart failure

Esophagus: boerhave's - what is seen on CXR, what is confirmatory test?

pleural effusion on CXR, water soluble contrast esophagram

Thyroid: how are most hyperthyroid patients managed (most common type of therapy, 2 main choices)?

medical therapy -- PTU/methimazole

Liver: who gets hepatic adenoma, what is it associated with?

most common in young women, associated with OCP use

Spleen: what myeloproliferative disorder benefits from splenectomy, what problem solved?

myelofibrosis -- extramedullary hematopoeisis in spleen

Biliary: what is needed normally for major CBD injury, and what is not needed?

need RNY hepaticojejunostomy, not hepatico or choledochoduodenostomy (never feasible)

Breast: what patient would get mastectomy/BCT + chemo (no tamoxifen)?

negative SLN, ER-

Breast: what patient would get only mastectomy/BCT + tamoxifen for 5 years (4 characteristics)?

negative SLN, old, ER+, and tumor <2 cm

Breast: what patient would get mastectomy/BCT + tamoxifen for 5 years plus chemo (4 characteristics)?

negative SLN, young, ER+, and tumor >1cm

Breast: what is treatment for inflammatory breast cancer (in order)?

neoadjuvant chemo, then mastectomy (mod radical), then XRT

Esophagus: what should never be done,for esophageal leiomyoma, when is surgery done, and what type/approach?

never biopsy (can form scar/difficult resection later); surgery if >5cm or symptomatic; excise (enucleate) via thoracotomy

Esophagus: what precedes boerhave's, and what are 3 symptoms seen?

preceded by vomiting after large meal; 1) resp distress; 2) chest pain; 3) fever

Breast: What is presentation, treatment, prognosis for intraductal papilloma?

presents with bleeding/bloody nipple discharge (most common cause), usually benign, biopsy/resect via major duct excision

Parathyroid: how common is parathyroid carcinoma and how does it often present?

rare -- often presents same way as parathyroid adenoma with signs/sxs hypercalcemia

Liver: focal nodular hyperplasia - what is usual size, symptom, appearance on liver scan, hallmark characteristic, and treatment?

size <5 cm, asymp, hot on scan, hallmark "central stellate scar", no treatment unless symptomatic (then resect)

Spleen: what is the treatment for varices with splenic vein thrombosis?

splenectomy

Colorectal: when is transanal excision OK (T stage, circumference, location, 2 criteria if invasive)?

stage - polyp or T1 circumference - <40% location - within 8-10cm of anal verge if invasive must be: 1) no lymphovascular invasion; 2) not poorly differentiated

Colorectal: HNPCC what other 6 organs at risk?

stomach, sm. bowel, urinary tract, ovary, pancreas and brain

Spleen: who (splenectomy for which disease) is at highest risk for overwhelming post-splenectomy infection (OPSI)?

thallassemia -- kids <4 also extremely high risk, FYI

Liver: amebic abscess - how does organism enter, what organism is it

through portal system

Liver: what disease is resectable?

unilobar or segment 1+2

Thyroid: if recognized postoperatively, what is treatment for recurrent laryngeal nerve injury and what can it allow (2 benefits)?

"medialization" of the cords, usually by injection directly into cords -- can allow: 1) improved phonation; 2) optimized glottic closure to prevent aspiration

Breast: What are the benign proliferative breast lesions that have increased risk of CA? (3) Tx?

- LCIS - Atypical ductal hyperplasia - atypical lobular hyperplasia Tx: resect the lesion w/ (-) margins

Breast: what are the axillary node levels (1-3, and one more category)?

1 - lateral to pec minor; 2 - beneath pec minor; 3 - medial to pec minor; Rotter's Nodes - between pec major and pec minor

Colorectal: what genes are altered in lynch syndrome (4) and what is their primary function?

1) MLH1: 2) MSH2; 3) MSH6; 4) PMS2 -- function in DNA mismatch repair

Breast: LCIS -- what is treatment (4 possibility, 2 things not needed ever)?

1) Need to resect the lesion but do not need neg margins 2) nothing and careful F/U 3) Hormonal therapy -(pre-meno: tamoxifen; Post-meno: raloxifene) 4) bilateral subcutaneous mastectomy (no ALND)

Breast: what are 3 chemo agents used for breast CA typically?

1) adriamycin; 2) cyclophosphamide; 3) taxol

Liver: how many segments, and what is each?

1) caudate; 2-4) left lobe (2-3 left lateral); 5-8) right lobe

Thyroid: what needs to be known about Hurthle cell/follicular neoplasm?

1) hard to diagnose carcinoma with FNA 2) treatment is the same for both

Thyroid: what are indications for surgery in hyperthyroidism besides large goiter with compressive symptoms (3)?

1) pregnant 2) failed medical management 3) hyperthyroid secondary to autonomously functioning thyroid nodule

Breast: What are contraindications to BCT (lumpectomy) in stage I breast cancer (and what specifically is not)?

1) prior irradiation; 2) pos margins; 3) inflammatory; 4) pregnancy (unless 3rd trimester)

Colorectal: what is treatment for familial adenomatous polyposis (3)?

1) total colectomy; 2) mucosal proctectomy; 3) pouch

Esophagus: what is risk for associated malignancy if barrett's esophagus and high grade dysplasia?

10%

Colorectal: what is polyp type, inheritence, associated cancer, and treatment for peutz-jeghers?

AD, hamartomatous polyps (nonmalignant) with mucocutaneous hyperpigmentation (oral), just endoscopic removal of polyps (no colectomy), associated with unusual sex cord tumors in women, Sertoli cell tumors in men

Colorectal: what is inheritence in HNPCC, and what is primary feature?

AD, right sided colon cancers without polyposis

Thyroid: what are bad prognostic factors for thyroid cancer (acronym / meaning of each)?

AGES A) Age - women > 50, men > 40 G) Grade - poorly differentiated is bad E) extent - extracapsular extension/regional LN disease S) size and sex - >4cm is bad, men are SOL

Breast: what is not needed for patient with negative SLNB?

ALND -- just do BCT or mastectomy depending on tumor is fine

Liver: echinococcal abscess - what is treatment?

Antiparasitics (albendazole/mabendazole) PA - Perc aspiration I - inject (w/ hypertonic saline or alcohol) R - resect

Liver: what is diagnosis of choice for liver hemangioma, and when is it "giant"?

MRI -- giant if over 10cm

Colorectal: how is colorectal cancer staged (2) and what is each best for (2)?

Total colonoscpy or EUS (T and N stage); CT (radial tumor eval/local invasion; distant disease)

Liver: treatment for pyogenic abscess (variuos options)?

abx and/or percutaneous drainage, always search for primary source

Thyroid: where does external branch of the superior laryngeal nerve travel along/with and innervate?

along inferior constrictors along with superior thyroid artery before entering and innervating cricothyroid (only muscle w/ this nerve)

Breast: for atypical ductal hyperplasia; atypical lobular hyperplasia; LCIS, how are these characterized and what treatment should be considered?

benign proliferative dz. Incr risk of CA. Need to resect - don't need (-) margins Can give hormone therapy - pre-meno: tamoxifen - post-meno: raloxifene Bilateral total mastectomy (no ALND)

Thyroid: what is done if pregnant patient is hyperthyroid and needs treatment?

beta block, then operate

Breast: what is main SE of adriamycin (doxorubacin)?

cardiomyopathy

Liver: pyogenic abscess - what are most common organisms (3)?

e. coli, klebsiella, strep

Esophagus: boerhave's - what is Rx if early, late, deathly ill?

early - primary repair (L thoracotomy) +/- G-tube and J-tube late - split fistula, G and J tube, delayed restoration of GI continuity deathy ill - mediastinal washout/drainage with definitive surgery when stable

Esophagus: if they show you barium swallow pic, and it's not achalasia, what is it probably?

esophageal leiomyoma

Colorectal: what is other primary risk in HNPCC in women?

endometrial cancer

Esophagus: what is Rx for non-high grade Barrett's?

endoscopic surveillance + rx of reflux (surgical or medical, no clear answer) is appropriate

upper GI - MALT tumor (lymphoma) - in typical presentation, what is first, second, and third line treatment?

eradicate H. pylori, chemo/xrt, surgery

Colorectal: what syndrome has autosomal dominant inheritence with pirimary feature of right-sided colon cancers without polyposis?

lynch syndrome (HNPCC)

Liver: can replaced right or left hepatic artery be ligated, and can both?

one or the other can be ligated if needed without significant issue

Biliary: lap chole injury to CBD - what characterizes minor injury and what is treatment?

recognized intra-op, repair primarily +/- stent

Thyroid: if recognized immediately (intra-op), what is treatment for recurrent laryngeal nerve injury?

repair nerve primarily

Liver: when does a hepatic artery branch go posterior to portal vein, and what is anatomy?

replaced right hepatic, from SMA, posterior to vein

Esophagus: what is arterial supply for gastric tube (reconstruction after esophagectomy)?

right gastroepiploic artery

Breast: what options are available for breast mass post neoadjuvant therapy?

same as de novo breast cancer -- BCT or mastectomy -- if tumor shrunk and now amenable to BCT, that's fine, even if it was big before and needed mastectomy based on size

Esophagus: what are indications for preop neoadjuvant chemo/xrt in GE junction cancer, and when should surgery come first?

surgery first if N0T1-2, neoadjuvant chemo/xrt if T3-4 or N+

Thyroid: what is treatment for Hurthle cell/follicular neoplasm if malignancy uncertain?

surgery, lobectomy always, since 20% at most will be carcinoma (for both types -- treatment is the same)

Breast: what is main SE of taxol?

taxol - neuropathy

Spleen: when do sickle cell need splenectomy?

they don't -- most auto-splenectomize by early age

Colorectal: carcinoid tumor rectum - what is treatment?

transanal excision typically, unless factors for transanal excision not met (see other question)

Thyroid: what is sequence of treatment for MEN-1 with hypercalcemia and a gastrinoma and why?

treat the parathyroids first, then the gastrinoma -- controlling hypercalcemia makes control of acid hypersecretion easier, and gastrinoma becomes elective