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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1232_Библиотеки_им_академика_М_И_Перельмана.pdf
34
K. Yoon-Flannery and C. N. Ford
Diagnostic Testing
• A bilateral diagnostic mammogram will need to be
ordered with comparison to prior imaging.
• Ultrasound may be useful for palpable masses and should
be performed with assessment of the ipsilateral axilla.
• MRI can be considered in order to assess the extent of
invasive disease.
• Image-guided percutaneous core needle biopsy should be
obtained for histologic conrmation of the suspected
diagnosis.
– If invasive breast cancer is identied, then hormone-
receptor status (i.e., estrogen receptor (ER), progesterone receptor (PR), and Her2/neu receptor) should be
evaluated. The ipsilateral axilla should also be examined and, if sonographically abnormal lymph nodes
are seen and/or palpated, then percutaneous biopsy
should be performed (either FNA or core needle).
• In cases of clinical Stage III breast cancer, evaluation for
distant metastases is recommended with use of a bone
scan and CT scan of the chest, abdomen, and pelvis (or
PET/CT scan). For Stages I and II breast cancer, workup
for invasive disease should only be performed if the
patient is exhibiting symptoms.
– In Stage III breast cancer, the tumor is large (more than
5 cm), is growing into nearby tissues (e.g., the skin
over the breast or the muscle underneath), and/or has
spread to nearby lymph nodes.
– If sites of distant metastases are identied, biopsies of
the metastatic lesions may be performed to conrm the
diagnosis.
– Tissue should also be analyzed for hormone receptor
status and histology.
Additional Testing
• For premenopausal women or those with a strong family
history, genetic testing should be considered. Indications
for genetic testing include:
– Multiple relatives with breast and/or ovarian cancer
– Age of diagnosis <35years of age
– A family member diagnosed with both breast and
ovarian cancer
– Breast and/or ovarian cancer in Jewish families
(Ashkenazi)
– Family members with primary cancer in both breasts—
especially if diagnosed <50years of age
– Family member diagnosed with invasive serous ovar-
ian cancer
– Presence of male breast cancer in the family
– Family member with an identied BRCA1 or BRCA2
mutation
– Breast cancer during pregnancy
– Triple-negative breast cancer diagnosed at age less
than 60
• In the presence of metastatic disease, the following labs
should be obtained:
– CBC
– CMP, including LFTs and alkaline phosphatase
Treatment
The current standard of care for stage IV breast cancer is
systemic therapy. The overall goal of treatment in the metastatic setting is to lengthen life span and improve quality of
life.
While there is not a proven survival benet to aggressive
local therapy, resection of the primary tumor can be performed for palliative purposes. It may also be considered in
select patients with a favorable response to initial systemic
therapy.
Systemic treatment is dependent on hormone receptor
positivity, the extent of visceral disease, and prior therapy.
• For ER- and/or PR-positive and HER2 negative
cancers:
– With bone or soft tissue metastases only OR limited
visceral disease:
Premenopausal: Tamoxifen with or without ovarian
ablation
Following ovarian ablation, use post- menopausal
endocrine options (e.g., Anastrozole)
Post-menopausal: Non-steroidal aromatase inhibitors with or without fulvestrant (if no prior aromatase inhibitor), Tamoxifen (if no prior use), or
Letrozole with or without Palbociclib
These treatments should be continued until disease
progression and/or unacceptable toxicity, at which
point an alternative endocrine therapy should be
utilized
• For ER- and/or PR-positive and HER2 negative can-
cers with extensive visceral disease:
– Chemotherapy should be utilized until progressive dis-
ease or maximum benet achieved
Options include Anthracyclines, Capecitabine,
Carboplatin, Cisplatin, Eribulin, Gemcitabine,
Ixabepilone, Taxanes, and Vinorelbine
If patient fails to respond to three sequential regimens, then chemotherapy should be discontinued
and palliative care should be discussed
• For ER- and/or PR-negative and HER2 negative
cancers:
– Chemotherapy should be utilized until progressive dis-
ease or maximum benet achieved
11 Metastatic Breast Cancer
35
Options include Anthracyclines, Capecitabine,
Carboplatin, Cisplatin, Eribulin, Gemcitabine,
Ixabepilone, Taxanes, and Vinorelbine
If patient fails to respond to three sequential regimens, then chemotherapy should be discontinued
and palliative care should be discussed
• For HER2 positive cancers:
– If no prior Trastuzumab or greater than 1 year since
adjuvant treatment:
Taxane chemotherapy plus Trastuzumab and
Pertuzumab
Alternate therapy is based on hormone receptor
status
– If less than 6–12 months from adjuvant Trastuzumab
or if prior (neo)adjuvant Pertuzumab:
T-DM1
Consider HER2 directed therapies
– If disease progresses, proceed to one of the following
regimens:
T-DM1 if not previously given
Capecitabine plus lapatinib
Trastuzumab plus lapatinib
Trastuzumab plus other chemotherapy
Chemotherapy or hormonal therapy (if ER or PR
positive)
Consider HER2 directed therapies
– If bone disease is present, denosumab, zoledronic acid,
or pamidronate should be added to the treatment
regimen.
Common Curveballs
• Cancer during pregnancy
• Recurrent metastatic disease as opposed to de novo
• Primary tumor is symptomatic
• Biomarkers differ between the primary tumor and site of
metastasis
Clean Kills
• Forgetting to examine both breasts
• Forgetting to order bilateral mammograms
• Not asking about receptor status on pathology
• Not assessing for regional or distant metastases
• Not recognizing that the patient has Stage IV disease
Summary
Metastatic breast cancer is a difcult topic for surgeons.
When presented with a patient who may have de novo
metastasis, it is important to complete an appropriate
staging work-up and to assess for hormone receptor status of both the primary tumor and metastatic disease.
Treatment for these individuals is multidisciplinary in
nature and requires systemic therapy. Palliative resection
may be considered for patients whose primary tumor is
symptomatic, but has not yet been demonstrated to
improve overall survival. Those patients presenting with
recurrent metastatic disease should be treated in a similar manner.
Bibliography
Gardishar WJ, Moran MS, Abraham J, Abramson V, Aft R, Agnese D,
etal. The NCCN breast cancer clinical practice guidelines in oncology. Version 4. 2023.
Jackson DP, Dodwell DJ. Metastatic breast cancer and palliative care.
In: Dixon JM, Barber MD, editors. Breast surgery: a companion to
specialist surgical practice. 6th ed. Great Britain: Elsevier Limited;
2019. p.257–68.
Menen R, Teshome M.Invasive breast cancer. In: Feig BW, Ching CD,
editors. The MD Anderson surgical oncology handbook. 6th ed.
Philadelphia, PA: Lipincott Williams & Wilkins; 2019. p.31–76.
Paget’s Disease oftheBreast
MicheleFantazzio
12
Dierential Diagnosis
• Eczema, dermatitis
• Squamous cell carcinoma or basal cell carcinoma
• Erosive adenomatosis (rare benign neoplasm of nipple)
• Drug eruptions
History
• Length of time rash present
• Used any topical preparations
• Bleeding
• Nipple discharge
• Itchy
Physical
• Unilateral or bilateral (bilateral is usually ECZEMA)
• Scaly, crusty
• Thickened, plaque
• Looks demarcated (not ECZEMA)
• 88% have underlying malignancy
• 50% with palpable mass
Treatment
• If just DCIS/Pagets that is considered Stage 0 resect entire
nipple and areolar complex and XRT
• If invasive present than need to do sentinel node, with
lumpectomy/mastectomy determined by extent of
disease
Sixty-two year old presents with a month-long rash on
areola that has not improved with hydrocortisone cream or
antifungal cream that her primary has prescribed to her. She
feels that the areola is thicker than usual and “bumpy”
• After you do a complete history and physical of both
breasts you notice a scaly lesion, ulcerative of the areola
• Mammogram and ultrasound were normal
• You then proceed with full thickness punch biopsy which
reveals Paget’s disease
• Upon further work up MRI of breast is normal, you can
then proceed to central lumpectomy (removal of nipple
and areola and central breast tissue), nal pathology has
clear margins and DCIS….. proceed with XRT.
Dierent Scenario
Patient above has a 3cm mass at 10:00in addition to lesions
Work-Up
• Always start with mammogram and ultrasound however
if negative still could be Pagets
• DEFINITIVE diagnosis is full thickness skin biopsy
• Can do MRI after diagnosis is made to help disclose
occult primary
M. Fantazzio (*)
Department of Breast Surgery, MD Anderson at Cooper Hospital,
Camden, NJ, USA
e-mail: fantazzio-michele@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_12
on nipple and areola. Biopsy of 3cm mass is invasive ductal
carcinoma ER/PR positive and Her2- negative and Pagets of
areola. MRI is done to ascertain the extent of disease and
there is at least 7cm of abnormal enhancement from areola
to upper outer quadrant.
37
38
M. Fantazzio
• Would probably proceed with mastectomy due to extent
of disease and needs axillary evaluation with ultrasound
and if there are no suspicious nodes can proceed with
mastectomy and sentinel node biopsy
Words ofWisdom
Stay calm. Always do history and physical, including family
history and HRT (hormone replacement therapy), ask about
genetic testing if family history is positive. Order mammograms and ultrasound and if negative and your clinical suspicion is high; ALWAYS biopsy. In general I think that the
examiners are not trying to trick you, just do things safely
and that will keep you out of trouble on the exam and in real
life. Good Luck!!
Bibliography
Chen CY, et al. Pagets disease of the breast: changing patterns of
incidence, clinical presentation and treatment in the U.S. Cancer.
2006;107:1448.
Dedes KJ, Fink D.Clinical presentation and surgical management of
invasive lobular carcinoma of the breast. Breast Dis. 2008;30:31–7.
Hussien M, Lioe TF, Finnegan J, Spence RAJ.Surgical treatment for
invasive lobular carcinoma of the breast. Breast. 2003;12:23–35.
Lopez JK, Bassett LW. Invasive lobular carcinoma of the breast:
spectrum of mammographic, US, and MR imaging ndings.
Radiographics. 2009;29:165–76.
Parvaiz MA, Yang P, Razia E, et al. Breast MRI in invasive lobular
carcinoma: a useful investigation in surgical planning? Breast J.
2016;22:143–50.
Practice guidelines. http://www.nccn.org/.
Part II
Colon and Small Bowel
Mesenteric Ischemia
KeshavKooragayala andMaureenMoore
13
Way Question May BeAsked?
A 70-year-old female with a history of atrial brillation on
coumadin presents with acute onset abdominal pain this
morning with bloody diarrhea and vomiting. She did admit
to forgetting to take her blood thinner this week. On examination of her abdomen, her pain is diffuse in nature with
rebound tenderness.
How toAnswer?
Full History
Character and timing of abdominal pain
Associated GI symptoms (nausea, vomiting, diarrhea
etc.)
Assessment of nutritional status
• Recent weight loss
• Postprandial pain (often associated with chronic mesenteric ischemia)
Functional assessment
Full Physical Examination
Focused abdominal exam
Vascular exam including distal pulses, presence/absence
of abdominal bruit
Diagnostic Tests
Prompt CT angiogram of chest/abdomen/pelvis with delays
Laboratory evaluation including CBC, BMP, PT/INR,
PTT, and lactic acid
Type and cross
Diagnostic angiography is still considered the gold standard
Management
Goal of surgery is to (1) restore blood ow and (2) evaluate
bowel viability
Medical Comorbidities
• Cardiac history
• Vascular history
• Elicit if patient has need for anticoagulation and timing of
last dose
• Hypercoagulable History (coagulation disorders, malignancy etc.)
Prior surgical history
K. Kooragayala · M. Moore (*)
Department of Surgery, Cooper University Health Care,
Camden, NJ, USA
e-mail: kooragayala-keshav@cooperhealth.edu;
moore-maureen@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_13
• Prompt uid resuscitation, IV heparin, and antibiotics
should be initiated
Acute SMA Embolism
• Most often, emboli lodge in SMA distal to middle colic
artery-> “Jejunal sparing” of proximal jejunum and transverse colon
• Key steps
– Midline laparotomy to assess bowel
– Exposure of SMA with cephalad retraction of trans-
verse colon, rightward mobilization of small bowel
– Embolectomy with Fogarty catheter after transverse
arteriotomy of SMA
41
42
K. Kooragayala and M. Moore
– Close vessel primarily or with patch
– Re-evaluate small bowel, consider second look for any
patchy ischemia within 24h
Acute SMA Thrombosis
• Also proceed with laparotomy and SMA exposure
• May need SMA bypass with right common iliac to SMA
with gentle “c-loop” to avoid kinking of vessel with
saphenous vein graft or ringed PTFE
Non-occlusive Mesenteric Ischemia
• Patients are often critically ill in the ICU on vasopressors,
leading to a low ow state
• Management requires correction of hypotension due to
primary disease process and supportive care with adequate resuscitation
• In select situations, can consider local vasodilator infusion with selective SMA catheterization
Mesenteric Venous Thrombosis
• Full anticoagulation, consider laparotomy to evaluate
bowel viability if ischemia is suspected
• Supportive care is mainstay of management
Clean Kills
• Not obtaining prompt CT angiography
• Inaccurate description of SMA exposure
• Only performing endovascular thrombectomy without
evaluation of bowel in setting of acute mesenteric
ischemia
• Primary abdominal closure in setting of patchy bowel
ischemia without plan for a second-look laparotomy
Summary
Mesenteric ischemia is often a surgical emergency. There
must be a low threshold to evaluate bowel viability and
restore vascular patency. Patients should be counseled
that there is high morbidity and mortality associated
with this disorder, and there should be a low threshold
for a second look laparotomy rather than primary
abdominal closure.
Common Curveballs
• No access to CT scanner (Proceed to diagnostic angiography)
• Patient has postoperative MI
• No saphenous vein available for reconstruction
• Other organ ischemia on exploration
• Post-operative short gut syndrome
Hemorrhoids
KristenKnapp andDanicaN.Giugliano
14
Hemorrhoids
• Hemorrhoids are classied as internal (located above the
dentate line) or external (located below the dentate line).
• Internal hemorrhoids are a normal part of the anal canal
within the submucosa, and can occur in three locations:
left lateral, right anterior, and right posterior.
– The arterial blood supply is from the terminal branches
of the superior hemorrhoidal artery and venous outow is from the superior, middle, and inferior hemorrhoidal veins.
– A classications system is based on degree of clinical
prolapse.
Grade I—no prolapse
Grade II—prolapse occurs but spontaneously
reduce
Grade III—prolapse occurs but has to be manually
reduced
Grade IV—prolapse occurs and cannot be reduced
• Symptoms occur for many reasons, including straining,
pregnancy, chronic cough, pelvic oor dysfunction, and
being erect.
– Bleeding (bright red), pain, and prolapse are the most
common symptoms
– Pain is not common for internal hemorrhoids, but can
occur with external hemorrhoids
He denies anorectal pain. He has constipation, with 1 bowel
movement every 3days, and usually has to strain.
What is your next step for evaluation?
• Physical exam is most common in the prone jackknife or
left lateral positions
• External anal exam is performed rst, followed by digital
rectal exam assessing for masses, pain and sphincter tone
• Anoscopic exam is then performed to better assess the
anal canal
What are your recommendations for this patient?
• Medical management includes 25g (for women) to 38g
(for men) of ber per day and at least 64 ounces of water
per day
• Stool softeners and/or laxatives can also be recommended
for patients with constipation
• Education on limiting time on toilet is important
• Sitz baths daily can decrease symptoms
• Topical therapy combines a barrier protectant in combination with either a vasoconstriction agent, local anesthetic,
anti-inammatory agent, or astringent
Oce-Based Treatments
A 38-year-old male comes to your ofce complaining of
bright red blood with bowel movements for the past 2months.
K. Knapp
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
e-mail: Knapp-kristen@cooperhealth.edu
D. N. Giugliano (
Division of Colon and Rectal Surgery, Department of Surgery,
Cooper University Hospital, Camden, NJ, USA
Cooper Medical School of Rowan University, Camden, NJ, USA
e-mail: giugliano-danica@cooperhealth.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_14
*)
• Rubber Band Ligation
– Effective for grade I-III internal hemorrhoids
– Using anoscopy, a rubber band is placed at the apex of
the internal hemorrhoid, high in the anal canal, 1–2cm
above the dentate line
– Blood ow is decreased caudally and hemorrhoids
shrink in size
– Blood per rectum can occur 5–7 days following
ligation
– Complications include delayed rectal bleeding (1%),
thrombosis, abscess, or urinary dysfunction
– Pelvic sepsis is rare but can be serious
43
44
K. Knapp and D. N. Giugliano
Pain, fever, and urinary retention are usually
symptoms
CT scan of the pelvis shows air outside the rectum
with inammation
Treatment includes going to the OR for debridement of the wound and drainage
– 18–32% of patients require repeat treatments when
following long-term
• Infrared Photocoagulation
– Infrared radiation is applied to apex of hemorrhoid and
leads to scarring and brosis
– Best used for bleeding symptoms and less for prolapse
symptoms
– Complications include pain and bleeding due to exces-
sive application of energy
• Sclerotherapy
– Best for patients that require anticoagulation since risk
of bleeding is minimal
– Injection of 1–1.5mL of phenol, carbolic acid, quinine
in urea, sodium morrhuate, or sodium tetradecyl, to the
submucosa of the apex of the internal hemorrhoid
leading to scarring and brosis
– Complications include mucosal sloughing if injected
too supercial or infection if injected too deep
– Less effective than rubber band ligation for grade III
hemorrhoids
A 59-year-old woman presents to your ofce 2 months
after undergoing a rubber band ligation of her internal hemorrhoids. She continues to report intermittent bleeding and
hemorrhoid prolapse. She is using a stool softener and ber
supplements and denies constipation or straining. Your examination in the ofce reveals grade III internal hemorrhoids.
What is your next step for treatment?
• Excisional hemorrhoidectomy
– Elliptical incision is made, starting at the perianal mar-
gin, and the hemorrhoid is lifted off of the underlying
sphincter muscle bers
– The vascular pedicle is clamped and suture ligated
using an absorbable suture
– The tissue is re-approximated if a closed technique is
used
– Energy devices (LigaSure bipolar device or harmonic
device) can also be used
• Complications
– Urinary retention is one of the most common
complications
Fluid restriction and pain control helps to prevent
urinary retention
– Postoperative hemorrhage
1% of the time bleeding will occur in immediate
postoperative period, and is a technical error
5.4% of patients will have bleeding 7–10days after
surgery
Anal canal packing with observation is rst
step
If bleeding continues, go to the OR for examination under anesthesia
– Anal stenosis
Occurs if excessive anoderm is removed, which
can occur during emergency hemorrhoidectomy
Treatments include bulk laxatives, anal dilation, or
anoplasty
– Postoperative infection
Less than 1% risk
If abscess or cellulitis occurs, antibiotics and/or
operative drainage may be necessary
– Fecal Incontinence
Uncommon, either from sphincter stretch or from
direct injury to the sphincter complex
Operative Management
• Required if continued symptoms despite medical management or in-ofce procedures
• 5–10% of patients with hemorrhoid symptoms require
operative hemorrhoidectomy
• Excisional hemorrhoidectomy is the gold standard for
long-term relief of symptoms
• Excisional hemorrhoidectomy can be done as a closed
technique or open (Milligan-Morgan) technique
– Patient is positioned lithotomy, prone jackknife, or left
lateral decubitus position
– Local anesthetic is used for the perianal skin
Special Scenarios
• Thrombosed external hemorrhoid
– Acute anal pain with perianal hard lump
– Pain is constant, and worse around day 3 or 4 after
onset of symptoms
– Thrombosis usually resolves on its own
– Spontaneous evacuation of clot can occur
– If patient has unrelenting pain, excise thrombus in the
ofce using local anesthesia
• Strangulated (grade IV) hemorrhoids
– May have urinary retention and referred pain
– Edema can lead to ulceration, necrosis and gangrene
– Urgent excisional hemorrhoidectomy in the OR usu-
ally needed
14 Hemorrhoids
45
Clean Kills
• Failing to discuss medical management for hemorrhoid
disease
• Failing to examine the patient including digital rectal
exam
• Failing to return to OR if signs of pelvic sepsis after
hemorrhoidectomy
• Rubber band ligation places distal to dentate line
• Rubber band ligation performed on patients on
anticoagulation
Bonus Points
• Pregnancy
– Symptoms usually resolve after delivery and rarely
need intervention
– 2% incidence of strangulation or gangrene requiring
hemorrhoidectomy
• Portal Hypertension and Hemorrhoids
– Rectal varices occur with portal hypertension and
rarely bleed
– If bleeding occurs from rectal varices, treatment
includes management of portal pressures, sclerotherapy, suture ligation, TIPS procedure
Words ofWisdom
• The management of hemorrhoids initially includes medical management and only a small portion of patients
require operative intervention. Ofce-based procedures
should be offered for grade I-III internal hemorrhoids and
are not used for external hemorrhoids. It is important to
know the comorbidities of patients with hemorrhoids, as
well as their medications, to recommend the best treatment option for patients.
Bibliography
Score. https://www.surgicalcore.org.
Steele SR, etal., editors. The ASCRS manual of colon and rectal sur-
gery. NewYork: Springer; 2019.