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Surgery Review 5
SR 5: Cardiothoracic, Vascular, Breast
| Question | Answer |
|---|---|
| What is the embryological origin of the breast? | Ectoderm milk streak |
| Which artery supplies 60% of total breast mass with blood flow? | Internal mammary artery |
| What is Batson’s plexus? | Valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine |
| Which quadrant of the breast can drain to internal mammary nodes? | Any quadrant |
| Describe the innervation to the pectoralis muscles | Medial pectoral nerve to pec major and minor; lateral pectoral nerve to pec major only |
| What biopsy findings in fibrocystic disease of the breast have an increased cancer risk? | Atypical ductal or lobular hyperplasia |
| What is the most common bacteria in a breast abscess? | S. aureus |
| What are common causes of infectious mastitis in a non-lactating woman? | Actinomyces, tuberculosis, syphilis, or autoimmune diseases (SLE). May need to rule out necrotic cancer with an incisional biopsy including skin |
| What causes noncyclical mastodynia, nipple retraction, and creamy nipple discharge? | Periductal mastitis (mammary duct ectasia or plasma cell mastitis) – dilated mammary ducts, inspissated secretions, and marked periductal inflammation |
| What is Poland’s syndrome? | hypoplasia of chest wall, amastia, hypoplastic shoulder, and no pectoralis muscle |
| What is the treatment for mastodynia? | Danazol, OCPs, NSAIDs, bromocriptine, and/or evening primrose oil. Make sure to discontinue caffeine, nicotine, and methylxanthines |
| What is Mondor’s disease? What is the treatment? | thrombophlebitis of superficial vein of breast. Cord like mass laterally. Treat with NSAIDS |
| What is the most common cause of bloody nipple discharge? | Intraductal papilloma – no risk of CA |
| What is the most likely diagnosis of a firm, rubbery, painless and mobile breast mass? Treatment? | Fibroadenoma. If <30 – FNA or core biopsy; if >30 excisional biopsy to ensure diagnosis |
| What % of DCIS develop invasive cancer? | 50-60% in ipsilateral breast |
| What is significant about the comedo subtype of DCIS? | Most aggressive subtype, has necrotic areas, high risk of microinvasion and recurrence. Treat with total mastectomy |
| What % of LCIS develop invasive cancer? | 30-40% in either breast |
| What is the difference pathophysiologically in cancer risk between DCIS and LCIS? | DCIS is a precursor to cancer LCIS is a marker of risk |
| What are the BI-RADS classifications and associated recommendations? | 1 – Negative (routine screening) 2- Benign finding (routine screening) 3 – Probably benign finding (short interval follow-up) 4 – Suspicious abnormality (consider biopsy) 5 – Highly suggestive of malignancy (appropriate malignancy workup and treatment |
| What are the locations of the axillary node levels? | I – lateral to, II – beneath, and III – medial to pectoralis minor muscle |
| Where are Rotter’s nodes? | Between pectoralis major and minor muscles |
| Describe the "T" staging of breast cancer | T1 = <2cm T2 = 2-5cm T3 = >5cm T4 = skin or chest wall involvement |
| Describe the "N" staging of breast cancer | N1 = ipsilateral lymph nodes (1-3 LN on path) N2 = fixed or matted LN (4-9 LN on path) N3 = infraclavicular, supraclavicular, or internal mammary (>10 LN on path) |
| Decribe the staging of breast cancer (TNM) | Stage I = T1 Stage IIA = T1N1 or T2N0; IIB = T2N1, T3N0 Stage IIIA = T1-3 and N2, or T3N1; IIIB = T4N0-2; IIIC = Any T N3 |
| How does hormone receptor status in breast cancer affect prognosis? | ER+PR+ > ER-PR+ > ER+PR- > ER-PR- |
| What genes are associated with breast cancer? | p53, bcl-2, c-myc, c-myb, her2neu |
| What are Hagensen’s criteria for unresectability of breast cancer (Hagensen’s Grave Signs)? | Skin ulceration, edema of <1/3rd of skin of breast, fixation of tumor to chest wall, axillary nodes >2.5cm, fixed axillary nodes |
| What are the gene mutations BRCA I and BRCA II associated with? | BRCA I – ovarian (50%) and endometrial cancer (consider TAH / BSO), BRCA II – male breast cancer |
| What is significant about dermal lymphatic invasion on pathology after breast biopsy? | Sign of inflammatory breast cancer |
| What are absolute contraindications to breast-conserving therapy requiring radiation? | Prior radiation to breast/chest wall, Radiation therapy during pregnancy, Diffuse suspicious or malignant appearing microcalcifications, Widespread disease not able to be incorporated by local excision, Positive margins |
| What are the indications for RT after mastectomy? | >4 nodes, skin or chest wall involvement, +margins, T3 or T4 tumor, N2 or N3 nodes |
| What is Stewart-Treves syndrome? | Angiosarcoma arising from chronic lymphadema, often as a complication after mastectomy. Presents as a purplish mass on arm ~10 yrs s/p MRM |
| What is the chance of recurrence with lumpectomy and XRT? | 10% (usually within 2 years) |
| What are the indications for chemotherapy in breast cancer? | >1 cm tumor or positive nodes (except postmenopausal women with positive estrogen receptors -> tamoxifen) |
| What is Paget's disease of the breast? Treatment? | Scaly skin lesion on nipple, suggesting underlying DCIS or ductal CA; Rx - MRM if cancer present, simple mastectomy if not |
| What % of Phyllodes tumor are malignant? | 10% (based on mitoses per high-power field >5-10) |
| What is the treatment for Phyllodes tumor? | Wide local excision, rarely mastectomy. No axillary node dissection necessary (spread is hematogenous, not lymphatic) |
| What is the mechanism of Tamoxifen? | Selective estrogen receptor modulator (SERM) |
| What is the mechanism of letrozole (Femara) and anastrozole (Arimidex)? | aromatase inhibitor |
| What are the risks and benefits of tamoxifen? | Decreases short-term risk of breast cancer 50-60%, 1% risk of blood clots, 0.1% risk of endometrial cancer |
| What are the risks and benefits of anastrozole (Arimidex)? | More effective than tamoxifen, particularly effective in ER+ PR-, side effects of bone loss and joint aches |
| What is the most common cause of hypercalcemia in breast cancer? | Parathyroid Hormone Related Peptide (PTHrP) |
| Describe the relevant anatomy of the diaphragm | T8 - vena cava; T10 - esophagus + vagus; T12 - aorta + thoracic duct |
| What is the course of the thoracic duct? | Runs on right side, crosses midline at T4-5, drains into left subclavian/internal jugular vein junction |
| What are the accessory muscles of respiration? | SCM, levators, serratus posterior, and scalenes |
| What is the difference between the two types of pneumocytes? | Type I: functional gas exchange, Type II: produce surfactant (1%) |
| What is the preoperative FEV1 recommended for a: wedge resection? lobectomy? pneumonectomy? | 0.6L; 1L; 2L |
| What is the required FEV1, DLCO, and FVC required after lung resection? | FEV1 > 0.8L (or at least 40% of predicted), DLCO > 12, FVC > 1.5L |
| What is DLCO? | Diffusing capacity of the Lung for Carbon Monoxide, based on pulmonary capillary surface area, hemoglobin content, and alveolar architecture |
| What preoperative ABG values prohibit lung resection? | pCO2 > 45 or pO2 < 50 at rest |
| What has the strongest influence on survival of lung cancer? | Nodal involvement |
| What are the two main types of non-small cell carcinoma? | Adenocarcinoma (most common lung CA, usually more central) and squamous cell (more peripheral) |
| What paraneoplastic syndrome is most common with squamous cell lung CA? small cell lung CA? | Squamous – PTH-related peptide, Small cell – ACTH, ADH |
| What anatomic landmarks are seen during a mediastinoscopy? | Right – azygous and SVC; Left – RLN, esophagus, aorta, main PA; Anterior – innominate vein/artery, right PA |
| When should a mediastinoscopy be performed for lung CA? | Suspicious adenopathy (>0.8cm or subcarinal >1.0cm) or centrally located tumors |
| What other cancer types benefit from isolated lung metastases resection? | colon, renal cell, sarcoma, melanoma, ovarian, and endometrial CA |
| What appears as a popcorn lesion on chest CT? | hamartoma – most common benign adult lung tumor |
| What are the common anterior mediastinal tumors? | Thymoma (most common anterior mass in adults), thyroid Ca, parathyroid adenomas and goiters, T-cell lymphoma, Teratoma and other germ cell tumors (most common in kids) |
| What are the common middle mediastinal tumors? | bronchogenic cysts, pericardial cysts, enteric cysts, lymphoma |
| What are the common posterior mediastinal tumors? | Neurogenic tumors (most common overall), enteric cysts, lymphoma |
| What is the relationship between thymomas and myasthesnia gravis? | 10% of MG have thymomas, but 90% respond to thymectomy |
| When do you resect a thymoma? | All require resection, 50% are malignant |
| What are the 3 phases of an empyema? | Exudative phase (1st week)-tx chest tube and abx; Fibroproliferative phase(2nd week)-tx chest tube and abx; Organized phase(3rd week)-fibrous peel around lung, likely need decortication |
| What lab values are associated with a chylothorax? | pleural fluid with increased lymphocytes and TAG (>110), sudan red stains fat |
| What is the definition of massive hemoptysis? Treatment? | >600cc/24hrs from high-pressure bronchial arteries. Place bleeding side down, main stem intubate opposite side, OR for lobectomy or pneumonectomy |
| When do you operate on a spontaneous pneumothorax? | recurrence, large blebs on CT, air leak > 7 days, nonreexpansion, high risk profession (diver, pilot), or patients in remote areas |
| What is pulmonary sequestration? Treatment? | mass of non-functioning primitive tissue in the lung. Extralobar - systemic artery and vein - resection not necessary. Intralobar (75%) - aorta in and pulmonary vein out - lobectomy for recurrent infections |
| Chest imaging shows a parenchymal lesion and enlarged hilar lymph nodes, what is the treatment? | This is a ghon complex (tuberculosis) – INH, rifampin, pyrazinamide |
| What causes improved exercise tolerance and pulmonary function after lung reduction surgery? | Increased elastic recoil |
| What do you suspect with a pansystolic murmur 2-7 days after an MI? | Post-MI VSD |
| What is the treatment of aortic dissections? | Ascending always needs surgery; descending gets medical management unless persistent pain or end-organ ischemia |
| What is the most common congenital heart defect? | Ventricular septal defect |
| What is a catamenial pneumothorax? | PTX occurring in temporal relation to menstruation, caused by endometrial implants in visceral lung pleura |
| Which congenital heart defects cause R –> L shunts? | Cyanotic heart disease – tetralogy of fallot, transposition, and truncus arteriosus |
| What are indications to repair a VSD? | CHF resulting in failure to thrive (most common reason), PVR>4-6 Woods units, or before shool age |
| What is the treatment for a patent ductus arteriosus? | Indomethacin - blocks PG production - effective in ~70% |
| What is the restenosis rate after PTCA? | 20-30% in <1 year |
| What is the best conduit for CABG? | Internal mammary artery - >90% 10 year patency rate |
| What are indications for CABG? | intractable symptoms, >50% left main, triple vessel disease, 70% LAD + 1 other vessel |
| Which patients should receive a tissue valve over mechanical valve? | For patients who desire pregnancy, have contraindications to anticoagulation, are older, or are unlikely to need another valve in their lifetime |
| What are the cardinal symptoms of aortic stenosis? | Angina – develops in 65%, mean survival 5 years; Syncope – 25% of patients, mean survival 3 years; Heart failure – mean survival 2 years (strongest prognostic indicator) |
| What vessels have the lowest oxygen tension? | Coronary veins due to high oxygen extraction by myocardium |
| What are the symptoms of postpericardiotomy syndrome? Treatment? | pericardial friction rub, fever, chest pain, SOB, diffuse ST elevation on EKG; tx: NSAIDS and steroids |
| What is the first sign of cardiac tamponade on echo? | Decreased right atrial diastolic filling |
| What is idiopathic hypertrophic subaortic stenosis? | marked hypertrophy of left ventricle and LV outflow tract, causing narrowing of LVOT during systole. Adequate volume is needed, as not enough afterload will cause aortic outflow tract to collapse, resulting in pulmonary edema |
| What is the key index of disease progression for mitral regurgitation? | Ventricular function |
| What layer of the vascular wall is primarily effected by atherosclerosis? By Hypertension? | Athersclerosis – intima, HTN – media |
| How do the internal and external carotid arteries communicate? | Ophthalmic artery (first branch off ICA) and internal maxillary artery (off ECA) |
| What is a Hollenhorst plaque? | Cholesterol embolus seen in a blood vessel of the retina, signifies atherosclerotic disease, usually of the ICA |
| When should you consider emergent CEA? | Fluctuating neurologic symptoms, or crescendo/evolving TIAs |
| What is the initial treatment of claudication? | smoking cessation, excercise, trental - not surgery |
| What is the most common CN injury during CEA? | vagus nerve (clamp application) - hoarseness |
| What is the treatment of carotid traumatic inury with major fixed deficit? | If occluded, do not repair (may exacerbate injury), if not occluded then repair |
| What is the most common site of a thoracic aortic transection? | Tears at ligamentum arteriosum just distal to left subclavian (deceleration injury) |
| What are the classifications of aortic dissections? | Stanford A – any ascending involvement, B – descending only; DeBakey I – Ascending and Descending, II – Ascending only, III – Descending only |
| What is the most common location of AAA rupture? | Left posterolateral wall, 2-4 cm below renals |
| When do you reimplant IMA during a AAA repair? | backpressure <40mmHg (poor backbleeding), previous colonic surgery, stenosis at SMA, or inadequate flow to left colon |
| Bloody diarrhea POD 2 after AAA repair - what is the next step? | sigmoidoscopy to evaluate for ischemia (due to loss of IMA) - if necrosis then take to OR |
| What are the most common organisms in mycotic aneurysms? | 1 – Salmonella, 2 – Staphylococcus |
| What are the types of endoleaks? | Type 1 – leak at attachment sites, 2 – backbleeding from lumbars or IMA, 3 – graft on graft, 4 – Porosity. Need to fix/revise types 1 and 3 |
| Describe the neurovascular structures in the lower leg compartments | Anterior – deep peroneal nerve, anterior tibial atery; Lateral – superficial peroneal nerve; Deep posterior – tibial nerve, posterior tibial artery, peroneal artery; Superficial posterior – sural nerve |
| What is Leriche syndrome? | Buttock or thigh claudication, impotence, and absent femoral pulses caused by lesion at aortic bifurcation or above |
| At what ABI do you start to get: Claudication? Rest pain? Ulcers? Gangrene? | ABI < 0.9 = claudication, <0.6 = rest pain (usually across distal arch and foot), <0.5 = ulcers, <0.3 = gangrene |
| What abnormalities are seen after reperfusion of ischemic tissue? | Lactic acidosis, hyperkalemia, myoglobinuria, compartment syndrome |
| What is a malperforans ulcer? Treatment? | Chronic foot ulcer usually at metatarsal heads found in diabetics with neuropathy. Tx: nonweightbearing, debridement (need to remove cartilage), antibiotics, assess need for revascularization |
| What is the most common peripheral aneurysm? | popliteal |
| What are popliteal aneurysms associated with? | 50% bilateral, 1/3 have AAA |
| What is popliteal entrapment syndrome? Treatment? | Medial deviation of popliteal artery around head of gastrocnemius muscle causing loss of pulses with platarflexion and intermittent claudication. Tx: Resection of medial head of gastrocnemius with possible arterial reconstruction |
| What are the success rates for BKA vs AKA? | BKA – 80% heal, 70% walk again, 5% mortality; AKA – 90% heal, 30% walk again, 10% mortality |
| What are the signs/symptoms of acute arterial emboli in a limb? | Pain, pallor, pulselessness, paresthesias, poikilothermia, paralysis |
| What is the cause and treatment of “blue toe syndrome”? | Flaking atherosclerotic emboli off abdominal aorta or branches, usually good distal pulses. Tx: may need aneurysm repair, endarterectomy, or arterial exclusion with bypass |
| What are the causes of renovascular hypertension? | Atherosclerosis (2/3) – left side, proximal 1/3, men; Fibromuscular dysplasia (1/3) – right side, distal 1/3, women |
| What is the most common type of thoracic outlet syndrome? | Neurogenic (95%) – ulnar nerve distribution (C8-T1) most common |
| What is the normal course of the subclavian artery and vein? | Vein passes over 1st rib anterior to anterior scalene muscle, then behind clavicle, artery passes between anterior and middle scalenes |
| What is the treatment of thoracic outlet syndrome? | Neurogenic – resection of cervical ribs, divide anterior and middle scalenes, +/- 1st rib resection; Arterial – cervical and 1st rib resection, divide anterior scalene, bypass graft; Venous – thrombolytics, anticoagulation (may eventually need surgery) |
| What are the watershed areas of the bowel? | Splenic flexure (Griffith’s point) and Rectosigmoid area (Sudeck’s point) |
| What is the medical treatment for nonocclusive mesenteric ischemia? | Volume resuscitation, glucagon, papaverine, nitrates, and increase cardiac output |
| What is median arcuate ligament syndrome? Treatment? | Compression of celiac artery causing chronic pain, weight loss, diarrhea, and a bruit near epigastrium. Tx: transection of median arcuate ligament with possible arterial reconstruction |
| When do you repair a splenic artery aneurysm? | Symptomatic, pregnant, or woman of childbearing age |
| What is the treatment for most visceral and peripheral aneurysms? | Exclusion and bypass graft (splenic and proximal common hepatic can just be excluded secondary to good collaterals) |
| What diagnostic procedure is contraindicated in Ehler-Danlos syndrome? | No angiograms – risk of laceration to vessel |
| What is the most common reason of failure of AV grafts for dialysis? | venous obstruction secondary to intimal hyperplasia |
| What is the source of a PE after IVC filter? | Ovarian veins, inferior vena cava superior to filter, or upper extremity |
Created by:
jclanton82
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