CELEBRITY ABSITE JEOPARDY

POTENT POTABLES

100

A 76 year old dialysis depenednt woman with a history of multiple prior abdominal operations presents to the emergency room with worsening abdominal pain. Workup rasises your suspicions for ischemic bowel. She last underwent hemodialysis 3 days prior, and is currently uremic. How will you best prepare the patient for emergent celiotomy? A: administer congugated estrogens B: Administer cryoprecipitate C: Administer desmopressin D: Arrange for dialysis E: Transfuse the patient with PRBC

What is C; administer desmopressin The patient has chronic renal failure which results in coagulopathy which much be corrected prior to surgery. The mechanism leading to the coagulopathy is thought to be due to uremic inactivation of vWF. vWF normally binds platelets to collagen, initiating formation of the platelet plug. Desmopressin (DDAVP) causes the release of vWF and Factor VIII fro mthe endothelium. TIme to effect of DDAVP is within 1 hour of administrationand may last for up to 4 hours. DDAVP may also be used to reverse platelet dysfunction caused by ASA as well as following cardiopulmonary bypass. Treatment dose is 0.3 ug/kg, typicalyl given as a single dose. Dialysis will correct the uremia, but not immediately correct the coagulopathy. HD can correct the platelet function transiently, but the heparin can contribute to bleeding, and the setup and onset of effect are slower than DDAVP. PRBC can correct the anemia, but does not affect the coagulopathy. Cryo can shorten bleeding time for up to 12 hours by increased vWF and Factor III levels, but large quanities may be required to correct a uremia coagulopathy. Conjugated estrogens are effective at shortening bleeding time in uremic patients, but onset of effect is 72 hours and they need to be administered over several days.

200

This is the sound a doggy makes

What is bow-wow or ruff.

300

A 39 year old male is referred to your clinic for treatment of a cecal mass diagnosed by surveillance colonoscopy. His father, paternal grandmother, and paternal uncle all developed colon cancer by their fifth decade. Mutation of which of the following genes is associated with this man's disease? A: APC B: BRCA1 C: BRCA 2 D: hMSH2 E: K-Ras

What is D; hMSH2 HNPCC, aka Lynch syndrome, is an autosomal dominant heritable disease caused by muations in DNA mismatch repair genes including hMSH2, hMLH1, hPMS1, and hPMS2. Polyps are smaller than those seen in other familial colorectal cancer syndromes, and usually number less than 100. HNPCC tumors typically originate in the right colon; however, they may present as multiple synchronous cancers. Clinical criteria for the diagnosis of Lynch syndrome include the Amsterdam criteria I and II as well as the Bethesda criteria. Amsterdam I: FAP msut be excluded, 3 relatives with colorectal cancer, 2 generations, 1 first degree relative, 1 diagnosis before age 50. Amsterdam II: 3 relatives with an HNPCC-associated cancer (colorectal, endometrial, ovarian, stomach, small intestine, biliary tract, ureter, renal pelvis and sebaceous gland adenomas) + relatives that meet the rest of the Amsterdam I criteria. AI & AII have 61% and 78% sensitivity in diagnosing Lynch syndrome, leading to the Bethesda guidelines which expand the criteria. The Bethesda guidelines include synchronous colon cancers, microsatllite instability, and synchronous HNPCC-related cancer. This patient meets AI criteria and should have his cancer submitted for microstaellite instability testing, undergo genetic counseling, and possible germline mutation analysis. Patients with HNPCC should have a total colectomy if cancer is suspected. K-Ras oncogene mutations are assiciated with >90% of pancreatic cancers. It is thought to be sporadic and occurs early in the accumulation of gene mutations leading to pancreatic adenocarcinoma. K=Ras is not associated with colorectal cancer. FAP is caused by mutations in the tumor suppressor gene APC. Patients have 100s-1,000s of polyps by age 25. Cancer by age 45. Polyps are small typically concentrated in left colon. Treatment is total abdominal colectomy with musosal proctectomy and ileoanal pull-through. BRCA1 & BRCA2 carriers have ~85% chance of developing breast cancer. Ovarian cancer is associated with both mutations. BRCA2 is associated with an increased risk of male breast cancer.

400

A 70 year old man with ascites secondary to cirrhosis presents for elective umbilical hernia repair. Should he be offered repair of his hernia? A: Hell no B: Yes, if he had a recent MI C: Yes, if he is leaking ascites D: Yes, if he's listed for a liver E: Yes, if it is significantly affecting his lifestyle

What is C; yes, if he is leaking ascites from the hernia. The repair of umbo hernias in cirrhotics is associated with a high rate of recurrence secondary to the production of ascites and nutritional deficiencies resulting in muscular wasting and fascial thinning. Up to 20% of patients with cirrhosis wil ldevelop a hernia of the anterior abdominal wall. Surgery is complicated by risk of hemorrhage due to variceal disruption, peritonitis, post op ascites leak, and hepatic decompensation. Patients leaking ascites are at increased risk of peritonitis and should be offered a repair. Minimizing the ascites preoperatively is critical. The recurrence rate without preoperative ascites control is 73%. Control of ascites can be acheived with fluid and salt restriction, diuretics, paracentesis, or TIPS (transjugular intrahepatic portosystemic shunt).

500

Four weeks after a deceased donor kidney transplant, the patient returns to the ED with BLE edema. IN spite of normal fluid intake he reports minimal urine output over 18hours. Cr is 1.4 from 1.0. After failure to respond to a fluid challenge, ultrasound reveals good perfusion, minimal hydronephrosis and a 3x4x6 cm hypoechoic mass adjacent to the renal pelvis of the allograft. What is the most likely cause of the patient's oliguria? A: Compressive hematoma B: Lymphocele formation C: Renal artery stenosis D: Renal artery thrombosis E: Ureteroneocystostomy stenosis

What is B: lymphocele formation The most common cause of urinary obstruction from extrinsic compression of the ureter at this point after transplant is a lymphocele. The lymphocele forms in the retroperitoneal space atthe iliac fossa devloped for the implantation of the allograft, due to disruption of the tiny lymphatics that surround the recipent's external iliac artery and vein, and the inability of this space to absorb lymph. Postoperatively, as lymph collects in the pernephric space, pressure is exerted on the ureter, resulting in obstruction which will manifest as oliguria. Ultrasound will reveal the offending colection as a hypoechoic mass with accompanying hydronephrosis. Treatment should be via percunateous drainage or laparoscopic creation of a peritoneal window. Ureteroneocystostomy stenosis is a techinal complication that occurs early. It can be minimized by placing a stent intraoperatively. Hydronephrosis without fluid collection would be expected. Vascular compromise usually occurs within the first few hours to days after a kidney transplant. This complications includes renal artery or vein thrombosis, arterial dissection, and pseuodaneurysm formation. Hemorrhage can result in obstructive symptoms due to pooling of blood around the ureter, but this almsot always a very early complication. Renal artery stenosis would msot likely occur months to years after transplantation and presents with oliguria, hypertension, and rising serum creatinine levels.

JAPAN US RELATIONS

100

A 60 year old man who sufferes from chronic alcoholism is admitted to the hospital with an episode of acute pancreatitis. He suffered similar episodes i nthe past, all of which have resolved without complications. He has an elevated amylase and CT shows a 4cm pancreatic pseudocyst. What is the best subsequent treatment? A: EGD B: Observation and seria lCT scans C: Perc drainage D: Puestow procedure E: Simple aspiration

What is B; observation and serial CT scans Pseudocysts are fluid collections, usually inflammatory in origin, that arise in or in close proximity to the pancreas. By definition, pseudocysts lack an epithelial lining. Most pseudocysts are seen in the context of either acute or chronic pancreatitis. A small proportion of pseudocysts are post traumatic. I Nchildren, trauma is the msot common etiology of pancreatic pseudocysts. PSeudocysts developing from acute pancreatitis usually are extrapancreatic, loculated collections of amylase-rich fluid that develops within 2 weeks of onset of the attack. It probably results from the disruption of a pancreatic duct or leakage fro mthe imflamed surface of the gland. A ductal communication is not typically demonstrable. Most will resolve spontaneously unless they contain a large amount of necrotic material or become infected. Some will persist and develop a wall of fibrous garnulation tissue. Pseudocysts >4cm are unlikely to resolve spontaneously.

200

A 72 year old man undergoes percutaneous transheptaic colangiography (PTC) and percutaneous biliary drainage (PBD) for obstructive jaundice secondary to pancreatic cancer. Following the PTC/PBD, he develops melena and bright red blood is seen in the biliary drain. Laboratory work reveals a drop in hematocrit and increase in his LFTs. What is the definitive treatment for this change in his condition? A: Biliary stent placement B: Endoscopic epinephrine injection at the site of the bleeding vessel C: Hepatic resection D: Transarterial embolization E: Whipple. Always do a Whipple for an emergency. Whipples are done best on Sunday. When the surgeon is hungover and the ophtho OR team is on call

What is D; transarterial embolization Hemobilia is bleeding into the bile duct resulting from communication between blood vessel and duct. Clinical manifestations include melena/hematemesis, RUQ pain, anemia, transient worsening of LFTs, and jaundice. If bleeding is profuse, thepatient will go into hemorrhagic shock. The site of communication between the vessel and the duct may be intra- or extra-hepatic. The most common causes are iatrogenic (67%), with perc liver procedures accounting for 38%. Liver biopsy and hepatectomy may also result in hemobilia. OThe rcauses include trauma, liver abscesses, mycotic aneurysms, vascular malformations, tumors, and hemorrhagic cholecystitis. Diagnosis may be unclear for months, as the presentation is typically indolent, unlike the patient in the question. Brisk bleeding may be difficult to differentiate from that originating from the stomach or duodenum. Slow bleeding may clot within the biliary tree leading to obstructive jaundice. Standard treatment for hemobilia secondary to erosion into a hepatic artery branch is to attempt transarterial embolization. Angiography detects over 90% of causes of major hemobilia with selective embolization successful 80-100% of the time. If hemobilia is secondary to erosion into a protal vein brnach, upsizing the PBD may be sufficient o prevent bleeding by inducing tamponade. Surgery is indicated if embolization fails or in the settings of hemorrhagic cholecystitis or hepatic necrosis. Surgical treatment entails selective ligation of the bleeding artery, which may require a segmental liver resection, or removal of the root cause (ie vascular malformation, mycotic aneurysm, etc). Mortality is <5%.

300

This movie title is taken from the name of the book "Gone With the Wind"

What is Dolly Parton

400

A 36 year old woman underwent banding for an internal hemorrhoid 1 week ago. She contacts your office complaining of a small amount of blood on toilet paper after defectation, but denies pain or fever. The next step in management is: A: Direct the patient tothe emergency room B: Instruct the patient to apply cold compresses t othe perineum C: Instruct the patient to take fiber supplementation and increase fluid intake D: Prescribe Nifedipine ointment BID to the perianal region E: Tell the patient to take a hefty dose of MTFU.

What is C; 2 heaping tablespoons of coarse-milled Metamucil and 8-10 glasses of water, every day, for the rest of your life. It is common for patients to experience sloughing of eschar with minimal bleeding 5-10 days post banding. Sitz baths can help ease pain and inflammation. Fiber supplementation wit hadequate fluid intake will soften stool and prevent local trauma to the surgical site. ASA should be avoided. Nifedipine is used to treat fissures, which is unlikely in the patient who is pain-free. Further intervention is warrented only if the bleeding is significant. Patients should undergo examination under anesthesis with ligation of the source of bleeding.

500

Workup for vomiting in a 46 year old woman with Crohn's disease reveals a stricture in the second portion of the duodenum. What is the best surgical management of this problem? A: Heineke-Mikulicz strictureplasty B: Pyloris preserving pancreaticoduodenectomy (Whipple, just go for it. Whipple is always the answer. You know you want it.) C: Resection of the affected segment with primary anastomosis D: Roux-en-Y duodenojejunostomy

What is A: Heineke-Mikulicz strictureplasty Duodenal involvement in Crohn's disease is typically in the form of stricture, ulceration, and edema. The duodenum is less likely to fistulize or form an abscess. Strictureplasty and bypass are used instead of resection. Most strictures are limited to the first or second portion of the duodenum, and may be managed via a strictureplasty i nthe manner of Heineke-Mikulicz. The technique calls fora longitudinal incision on the antimesenteric border of the stricture, followed by transverse closure. Longer strictures should be managed with side to side retrocolic gastrojejunostomy. Due to the ulcerogenic nature of this procedure, a truncal vagotomy, or a highly selective vagotomy should be performed concurrently. Disease affecting the distal duodenum only is amenable to bypass via Roux-en-Y duodenojejunostomy. A vagotomy is not necessary for this procedure.

FAMOUS HORSEMEN

100

This is the only month that begins with "Feb"

What is Febtober or Febturday

200

A 76 year old man with aortoiliac occlusive disease undergoes percutaneous transluminal angioplasty of his left common iliac artery. What is the patency rate for patients who undergo angioplasty for iliac occlusive disease? A: 10% at 5 years B: 20% at 5 years C: 30% at 5 years D: 60% at 5 years E: 80% at 5 years

What is D; 60% at 5 years Percutaneous transluminal angioplasty for stenotic lesions in peripheral arteries is considered a viable option for patients at high risk fro surgery. The use of angioplasty instead of vascular bypass avoids the risks and complications of anesthesia, and is associated with shortened hosptial stays and more rapid return to normal activities. The overall patency of angioplasty include vascular dissection, vessel rupture, and distal embolization, which may ocure up to 4% of the time.

300

A 68 year old man presents with pain in his left leg. Examination and workup confirm diagnosis of a politeal aneurysm. What is the most common complication of PA that would result in the patient's leg pain? A: Aortic aneurysm rupture B: Nerve impingement by the popliteal aneurysm C:Popliteal aneurysm rupture D: Thromboembolic events associated wit hthe popliteal aneurysm E: Venous obstruction by the popliteal aneurysm

What is D; Thromboembolic events associated wit hthe popliteal aneurysm Fifty to eighty percent of patients with popliteal aneurysms present with symptoms most commonly due to ischemia. Ischemia develops due to thrombosis of the aneurysm, distal embolization to the tibal or pedal arteries, or a combination of these. The resulting ischemia may manifest itself in a range from mild claudication to gangrene depending on the extent of thrombosis and embolization. TE ultimately occurs in up to 35% of PAs if left untreated. Less common complications of popliteal aneurysms include venous obstruction and nerve impingement due to local compressiom by the aneurysm. PA rupture is rare, occurring in less tha n5% of patients. Popliteal aneurysms are the most frequent site of peripheral arterial aneurysms. 95% are caused by atherosclerosis, and they occur bilaterally 40%-60% of the time. Of note, there is a high incidence of other concurrent aneurysms, so examination must be inclusive for abdominal, iliac, and femoral artery aneurysms. THe incidence of concomitant abdominal aortic aneurysm is approximately 25%. Diagnosis is initially clinical, with a palpable, pulsatile mass. I nthe case of thrombosis, the mass will be firm. Confirmation of physical exam findings is made via ultrasound or CTA.

400

A 68 year old man with A-fib presents to the ED with a cool, pulselss right foot. Sensation is intact. Duplex ultrasound of the right leg reveals multiple femoral stenoses and tiboperoneal thrombosis with poor tibial flow. What is the most appropriate management? A: Amputation B: Diagnostic angiography C: Intra-arterial site-directed thrombolysis D: Percutaneous embolectomy under local anesthesia E: Systemic anticoagulation only

What is C, Intra-arterial site-directed thrombolysis Thrombolysis is indicated for patients with no or only mild snesorimotor deficits. Furthermore, this technique is useful when complete clot evacuation is unlikely using surgical embolectomy, or when the distal vessels are also occluded preventing inflow patency. A confirmatory angiography should be performed following intra-arterial site-directed thrombolysis. Arterial narrowing may preclude balloon catheter placement for surgical embolectomy in some patients. I nthese cases, a guidewire can be passed into and through the clot, followed by an infusio ncatheter. Arteriography can be performed to confirm the extent of clot and to guide catheter placement. Then, lytic agents can be injected through side holes in the catheter, perfusing the clot from within. Intra-arterial site-directed thrombolysis allows simulataneous identification of the nature of the lesion via angiography, suggesting stenting or balloon dialtion of stenoses. In addition, this allows for the monitoring of progress in thrombolysis. If thrombolysis is not progressing, surgical therapy may be indicated. Thrombolysis should not be used for common femoral artery emboli. Absolute contraindications to lytic therapy include active internal bleeding, CVA within 2 months, and intracranial disease. Relative contraindications include surgery or trauma within 10 days, likelihood of left heart thrombus, episodes of serious GI bleeding within 90 days, HTN, pregnancy, bacterial endocarditis, and diabetic hemorrhagic retinopathy.

500

Eighteen months after undergoing an aortobifemoral artery bypass, a 74 year old man presents with a painful swelling in his left groin. Ultrasound demonstrates a pseudoaneurysm at the site of the diatal anastomosis with surrounding fluid. What is the likely underlying cause of this finding? A: Atheroembolism B: Graft failure C: Graft infection D: Graft thrombosis E: Suture failure

What is C, Graft infection Anastomotic disruption is the cause of delayed hemorrhage in vascular grafts. While the exact cuase of disrutption is usually unknown, graft infection is suspected in most cases. Infection by virulent bacteria usually results in graft infections within 4 months of surgery. Patients develop signs of sepsis as well as evidence of local infection. Bacteria contributing to early graft infection include Staph A., Proteus, Klebsiella, Enterobacter, and PSeudomonas, all of which produce proteases that break down the arterial wall adjacent to the anastomosis. This results in a separation of the graft from the host artery, creating a pseudoaneurysm. These may rupture, thrombose, or embolize. Less virulent bacteria such as Staph epi may cause delayed graft infections. Infection of the graft may originate from septic emboli, usualyl from mitral or aortic valves, or from direct contamination of the graft during initial surgery. Successful treatment of graft infection includes systemic antibiotics and frequently graft removal and revision. Poor suture technique has been suspected as a cause of graft failure. However, studies have shown that msot cases of anastomotic disruption are due to graft infection.

AN ALBUM COVER

100

Which of the following is a characteristic of Merkel cell carcinoma? A: Early distant metastases B: Frequently cured with wide local excision alone C: Histologically similar to squamous cell carcinoma D:Locally aggressive tumor with low chance of distant spread E: Slow-growing, well-defined cutaneous lesion

What is A: Early distant metastases Merkel cell tumors are histologically similar to basal cell carcinomas but are both locally aggressive and commonly demonstrate distant metastases to nodes, viscera, and bone. On H&E staining they appear as deeply basophilic cell clusters in the dermis with nuclei that do not demonstrate severe atypia. They may stain positive for enolase, allowing differentiation between Merkel cell tumors and basal cell carcinomas. In addition, using keratin antibodies a distinct perinuclear dot pattern is seen with aggregation of antibodies at the nuclear border. CT or MRI should be used to evaluate for distant metastatic disease. They are difficult to treat , but common therapy consists of surgery (with 2-3 cm margins when possible), elective regional lymphadenectomy or sentinel lymph node biopsy, and radiation. Radiation therapy is useful as adjuvant therapy for both local and regional control and can also be used when surgery is not an option. Chemotherapy is currently under investigation.

200

Which of the following is a characteristic of a cutaneous lymphatic malformation? A: Bluish mass with overlying telangiectasias B: Cystic mass with overlying vesicles C: Firm, nodular mass D: Irregular mass fixed to underlying tissues E: Pulsatile ballotable mass

What is B: Cystic mass with overlying vesicles Cutaneous lymphatic malformations often present as cystic masses with overlying vesicles. A lymphatic mass would not be associated with telangiectasias, it would not be nodular or pulsatile, and it would not be fixed to underlying tissues

300

During resection of a pelvic tumor, the left ureter is inadvertently transected below the level of the pelvic brim. The immediate treatment of this problem is: A: Delayed repair and percutaneous drainage of urinoma B: Diversion with ureteroenterostomy C: Primary repair D: Primary repair with ureteral stent E: Ureterocystostomy

What is E: Ureterocystostomy Ureteral injuries are a common and feared complication of pelvic surgery. The common ways that ureters are injured include crushing injury by inadevertent clamping, electrocautery injury, and inadevertent resection as part of a specimen. In cases where the ureter is ligated, pressure hydronephrosis develops which can lead to urosepsis. In addition, the pressure can lead to necrosisof the remaining ureteral wall, which can rupture and allow urine to freely extravasate into the abdomen leading to urinoma formation. The treatment of ureteral injury depends on the injury type. The minor injuries, where there is a partial transection, the ureter can be closed primarily over a stent. For complete transections, in which the ureter is completely transected, primary closure (ureteroureterostomy) should be attempted. In cases of injury below the pelvic brim, ureteroureterostomy can be difficult and a ureterocystostomy is the procedure of choice to re-establish continuity with the urinary tract.

400

A 32 year old male is brought to the emergency department after his left leg was pinned between two cars. Upon examination, his left leg is swollen and tense below the knee and you suspect compartment syndrome. Which nerve is most commonly injured during fasciotomy of the lower leg? A: Deep peroneal nerve B: Lateral femoral cutaneous nerve C: Saphenous nerve D: Superficial peroneal nerve E: Tibial nerve

What is D: Superficial peroneal nerve Fasciotomy of the four compartments of the lower leg may be performed through one or two skin incisions, although the two-insicion technique is more common. The lateral incision is placed 2 cm posterior to the posterior medial edge of the tibia, releasing the superior and deep posterior compartments. Both incision should span the length of the leg. The correct placement of these two incisions will leave an 8-10cm skin bridge that will be unlikely to necrose. Injury to the superficial peroneal nerve may occur while performing the lateral fasciotomy, as this nerve travels superficially along the fascia between the anterior and lateral compartments. The tibial and deep peroneal nerves are both deep to the incisions needed for fascial release, and less likely to be transected. The saphenous nerve travels along the lateral border of the tibia, and as such runs parallel and anterior to the posterior skin incision. The lateral femoral cutaneous nerve innervates the lateral aspect of the thigh.

500

This color ends in "-urple."

What is light -urple or Jaleel White

CONDIMENTS

100

A 39 year old female presents t othe emergency department with complaints of watery diarrhea and upper abdominal pain for the past 2 weeks. On workup, she is found to have a small mass in te body of the pancreas on CT scanning. Laboratory abnormalities include a hemoglobin of 8.7, WBC of 10.1, hypokalemia, and a metabolic acidosis. She is subsesquently scheduled to have an exploratory laparotomy. Intraoperatively, the mass is removed from her pancreas an dmultiple small nodules are found in her liver. Considering the most likely diagnosis, what are her best treatment options? A: 5-fluorouracil and interferon-alpha B: IV steroids alone C: No further treatment is indicated D: Octreotide and glucocorticoids E: Repetitive embolization of the hepatic artery

What is A; 5-fluorouracil and interferon-alpha VIPomas are usually neuroendocrine islet cell tumors of the pancreas that produce high amounts of VIP. Othe rsecreted hormones may include secreted gastrin and pancreatic polypeptide. Clinical diagnosis is based on a history of ~10 watery stoold per day. Fecal losses while fasting are at least 20mL/kg/day but exceed 50mL/kg/day in msot cases. Fecal loss of large amounts of potassium and bicarbonate cause hypokalemia, acidosis, and volume depletion. Surgical exploration with tumor resection leads to cure in 50% of patients. In patients with metastatic disease, there are a number of treatment options. In advanced stages of the disease, tumor debulking may relieve symptoms but is not effective in al lcases. In adults, selected patients may have orthotopic liver transplantation. Serum VIP levels may normalize within an hour of curative tumor resection. Repetitive hepatic artery embolization may provide palliation over a long period for patients with liver mets but is not curative. Somatostatin analogs and conventional chemotherapy regimens have been effective in controlling some of the symptoms but were not effective on VIPoma syndrome and tumor progression. The combination of 5-FU and IFN-alpha has been found to result in major clinical improvement associated with tumor regression.

200

a 52 year old woman presents to your clinic with a palpable thyroid nodule. Ultrasound shows a 3cm lesion in the right thyroid lobe with solid and cystic components. Ultrasound-guided fine needle aspiration reveals a thyroid cancer. Which of the following is the most likely diagnosis? A: Anaplastic carcinoma B: Follicular carcinoma C: Medullary carcinoma D: Papillary carcinoma E: Parathyroid adenocarcinoma

What is D; Papillary carcinoma Thyroid cancer may be divided histologically into (1) well-differentiated (papillary, follicular variant of papillary, follicular, and Hurthle cell) carcinoma (2) medullary carcinoma and (3) undifferentiated or anaplastic carcinoma Papillary carcinoma constitutes 80% of all thyroid cancers. On histology, the tumor cells have the characteristic "Orphn Annie eye" (empty-appearing nuclei) appearance, and psammoma bodies are typically present. Papillary carcinoma is multifocal at presentation 75% of the time. Therefore, treatment of lesions 1cm or larger consists of total thyroidectomy. Central (level VI) neck lymph node dissection is added if suspicious nodes are present or the estimated risk of recurrence is high. Prophylactic neck dissection is advocated by many endocrine surgeons as well. Patients are usually treated with 131I postoperatively based o ntheir risk of recurrence. Papillary carcinoma is associated with a 90% survival. Follicular carcinoma constitutes approximately 15% of well-differentiated thyroid cancers. FMA results may be suggestive of a follicular neoplasm, but a diagnosis of cancer can only be made on final histopathology with documentation of vascular or capsular invasion. Treatment is total thyroidectomy followed by postoperative 131I. Ten year survival is estimated at 85%. Medullar ycarcinoma constitutes less than 1% of al lthyroid cancers, and arises fro mthe neuroendocrine parafollicular C cells. Fifteen percent of cases are associated with MEN 2A and 2B syndromes. FMA is diagnostic with positive immunostaining for calcitonin. Medullary carcinoma should be treated with total thyroidectomy and central neck dissection at a minimum. Modified radical neck dissection is indicated for lateral cervical lymphadenopathy. The overall 10 year survival is 50%.

300

A 55 year old woman presents to your clinic with a new diagnosis of tertiary hyperparathyroidism. Which of the following operations has she most likely previously undergone? A: Colectomy with resection of terminal ileum B: Parathyroidectomy C: Renal transplantation D: Right middle lung lobectomy E: Thyroidectomy

What is C; Renal transplantation Tertiary hyperparathyroidism is persistent abnormal hypersecretion of parathyroid hormone (PTH) afte rcorrection of causes of secondary hyperparathyroidism. PRimary hyperparathyroidism is due to inappropriate secretion of PTH caused by a parathyroid adenoma or parathyroid hyperplasia. Secondary hyperparathyroidism is a result of compensatory increase of PTH secretion in response to hypocalcemia from nonparathyroid cause. This is most commonly due to renal failure, which causes hyperphsphatemia, hypovitaminosis D, and resultant hypocalcemia. Classically, tertiary hyperparathyroidism is seen in the setting of a patient with long-standing secondary hyperparathyroidism, who has had a renal transplant for dialysis-dependent renal failure. The compensatory hypersectretion of PTH of secondary hyperparathyroidism persists after correction of the renal failure and becomes autonomous (tertiary hyperparathyroidism) as a result of parathyroid hyperplasia or new parathyroid adenoma. Patients usually present with normal to high calcium levels, and elevated PTH levels. Indications for surgery in tertiary hyperparathyroidism include severe hypercalcemia (>11.5), persistent hypercalcemia (>10.2) for more than 3months-1 year post transplant, and severe osteopenia and persistent symptoms of hyperparathyroidism (boen and joint pain, pathologic fractures, genrealized muscular weakness, fatigue, renal stones, metnal status changes, peptic ulcer disease, pancreatitis, and calciphylaxis. Surgical management is either subtotal (three and a half glands) parathyroidectomy or total parathyroidectomy with with autotransplantation.

400

This Ringo was the "Starr" drummer for the Beatles.

Who is Craven Morehead

500

A 47 year old woman presents with a rapidly enlarging 5cm breast mass without palpable axillary lymph nodes. FNA is nondiagnostic. Core biopsy is performed and results are equivocal, but suggestive of a phyllodes neoplasm. The appropriate next step inmanagement is: A: Close follow up B: Simple mastectomy C: Tumor enucleation D: Tumor excision with a 1cm margin E: Tumor excision with a 2cm margin and sentinel node biopsy.

What is D; Tumor excision with a 1cm margin Phyllodes tumors are breast neoplasms composed of an epithelial component, which is always benign, and a stromal component that can be benign (60%), borderline (15%), or frankly malignant (25%). They account for <1% of all breast tumors and share morphlogic similarities with fibroadenomas, but their peak incidence is in the fourth and fifth decades of life. PHyllodes neoplasms present as breast masses, sometimes rapidly enlarging, but rarely cause additional symptoms/ Mammography and ultrasound cannot reliably distinguish fibroadenoma from phyllodes tumor, while FNA is diagnostic only in a monority of cases. Core needle biopsy is more accurate, although recent studies have failed to yeild consistent recommendations regarding its use. Due to rapid growth and potential for malignancy, surgical treatment of phyllodes tumors is mandatory. Simpel tumor enucleation is insufficient due to high recurrence rates, even for benign tumors. There is no role for sentinel node biopsy because malignant phyllodes tumors behave like sarcomas, rarely causing lymph node metastases. Recent data suggest that wise local excision with a 1cm margin is adequate even for malignant tumors, yielding the same survival despite higher recurrence rates.