SURGERY SAQs

These questions are worth 20 points each with many parts/sections.

1. 1).A 3 year old child presents with an abnormally enlarged abdomen, abdominal
pain, fever, nausea & vomiting, hematuria. He also has a BP of 150/90mmHg
(HTN).
a). What is the diagnosis? Wilms Tumor (Nephroblastoma)
Wilms Tumor is a rare, malignant tumor of the kidney, of a type that occurs in
young children. It is the most common abdominal malignant tumor. The median
age at diagnosis of Wilms tumor is approximately 3.5 years. With current
multimodality therapy, approximately 80-90% of children with a diagnosis of
Wilms tumor survive. It is highly responsive to treatment with about 90% of
patients surviving at least 5 years.
Wilms tumor is thought to be caused by alterations of genes (WT1 gene- Wilms
tumor gene) responsible for normal genitourinary development. Examples of
common congenital anomalies associated with Wilms tumor are cryptorchidism,
a double collecting system, horseshoe kidney, and hypospadias. Environmental
exposures, although considered, seem relatively unlikely to play a role. These
children will have aniridia, genitourinary anomalies, and mental retardation
(WAGR syndrome). It is relatively more common in blacks than in whites.
Most of these tumors are unilateral but 5% are bilateral. They tend to be
encapsulated and vascularized tumors that do not cross the midline of the
abdomen.
Presentation:

History:
o Asymptomatic abdominal mass( most common manifestation)
o Abdominal mass(occurs in 80% of children at presentation)
o Abdominal pain
o Hematuria
o HTN
o Hypotension, anemia & Fever( may occur)
o UTI & varicocele(are less common findings)
Physical exam:
o Palpable abdominal mass
o WAGR syndrome

- In order to make a diagnosis this needs to be followed by doing a history

and physical exam. The first sign is normally a painless abdominal; tumor that
can be easily felt by the doctor.
b). What investigations would you do for this tumor?

Lab studies: CBC, U&ES(electrolyte imbalance from vomiting), Calcium,

urinalysis, Coagulation studies, GXM
Cytogenetic studies: including 1p and 16q deletion
Imaging: ABD USS(Renal ultrasound), CT SCAN ABD( to determine the
origin of the tumor, involvement of lymph nodes, bilateral kidney
involvement, invasion of major vessels(e.g. Inferior vena cava), and liver
metastases), MRI ABD(most sensitive modality for determination of caval
patency and be important in determining whether the inferior vena cava is
directly invaded by the tumor)
Biopsy: for confirmation, the tumor contains bone, muscle, cartilage (it is a
triphasic type-blastema, mesenchyme, and epithelium). Histopathological
confirmation of Wilms tumor is essential. Lymph node biopsy are obtained
for staging purposes.
c). What operation is required, the definitive treatment?
- Definitive treatment is surgery consisting of Nephrectomy with Lymph node
sampling followed by a regimen of Chemotherapy (Vincristine) +/- Radiation
d). What long term follow up?
- The lungs are the most common site of relapse. This site is affected in more
than two thirds of children who have a relapse.
- The patient must be examined at the follow-up clinic after he or she completes
all therapy. -The purpose of follow-up care is to check for recurrence and for late
effects of therapy.
- Stages I, II & II with favorable histology must have a CXR and follow-up 6
weeks and 3 months after surgery, then every 3 months, then every 6 months,
then yearly ( 2 times).
e). What differential diagnosis (2)?

Neuroblastoma
Pediatric Polycystic Kidney Disease
Pediatric Rhabdomyosarcoma
Other( Renal cyst, Hydronephrosis, Dysplastic kidney, Renal cell
carcinoma)
f). Prognosis: overall 5 year survival rate is ~90% with current multimodality
therapy. Patients who have tumors with favorable histology have an overall survival rate
of at least 80% at 4 years after the initial diagnosis even in patients with Stage IV
disease. Patients with anaplastic Wilms tumors have a worse prognosis compared with

favorable histology; the 4 year survival rate is 83 %( stage I), 83 %( stage II), 65 %(
stage III), & 33 %( stage IV).
g). Complications:
- The tumor may grow very large
- Tumor may rupture
- Spread to the lungs (most common metastases site), liver, bone, or brain
- HTN
-Kidney damage/failure
2. A 68 year old man presents to clinic with a history of urinary frequency, nocturia,
urinary urgency, hesitancy, incomplete bladder emptying, straining, decreased
force of stream, dribbling. He has had a UTI in the past two weeks as well and
had slight hematuria and minimal pain.
Benign prostatic hyperplasia (BPH), also known as benign prostatic hypertrophy, is a
histologic diagnosis characterized by proliferation of the cellular elements of the
prostate. Chronic bladder outlet obstruction (BOO) secondary to BPH may lead to
urinary retention, renal insufficiency, recurrent urinary tract infections, gross hematuria,
and bladder calculi.
The area affected by BPH is the Transition Zone, which surrounds the urethra and this
is removed during either TURP or Open Prostatectomy.
As a man ages his prostate gland will continue to grow and this will eventually cause
symptoms of bladder outlet obstruction.
Signs & Symptoms:
Urinary frequency
Urinary urgency
Hesitancy
Incomplete bladder emptying
Straining
Decreased force of stream
Dribbling
Diagnosis: Complete history & Physical exam
- DRE is an integral part of the evaluation in men with presumed BPH. The prostate size
and contour can be assessed, nodules can be evaluated, and areas suggestive of
malignancy can be detected.
a).What diagnosis? Acute urinary retention secondary to BPH (Benign Prostate
Hypertrophy)

b). What investigations?

Lab studies: CBC, U&Es, PSA, Urinalysis, Urine culture

Imaging: Ultrasonography( Renal, ABD, Transrectal) and IV Urography(
useful for helping determining bladder & prostate size and the degree of
hrdonephrosis(if any) in patients with urinary retention or signs of renal
insufficiency, However, they are not indicated for the initial evaluation of
uncomplicated LUTS.
Optional tests: Flow rate, is useful in the initial assessment and to help
determine the response to treatment. It may be performed prior to embarking
on any active treatments, including medical treatment.
Endoscopy of the Lower Urinary Tract: Cystoscopy may be indicated in
patients scheduled for invasive treatment or in whom a foreign body or
malignancy is suspected. It can also be indicated in patients with history of
STDs (e.g. gonococcal urethritis), prolonged catheterization, or trauma.
Findings may suggest urethral stricture as the cause of Bladder outlet
obstruction instead of BPH.
c). What management- drugs, operations, indications for operation?
- Watchful Waiting: is used in patients with mild symptoms of LUTS secondary to
BPH and who are not bothered by these symptoms.
-Definitive Treatment is Surgery: Transurethral Resection of the Prostate (TURP),
this is the criterion standard for relieving bladder outlet obstruction secondary to
BPH. This is a minimally invasive procedure and provides no cutting of the skin. It
uses heat to destroy the prostatic tissue. It is all done through the penis by using a
cystoscope and a resection instrument to remove the prostate. It is a type of
Prostatectomy.
----Open Prostatectomy: is reserved for patients with very large prostates (>75g),
patients with concomitant bladder stones or bladder diverticula, and patients who
cannot be positioned for transurethral surgery (Lithotomy position). This procedure
requires a lower abdominal incision and the inner core of the prostate, the transition
zone is shelled out, thus leaving the peripheral zone behind.
- Indications for surgery:

Indications for TURP:

o Refractory urinary retention
o Recurrent UTIs due to prostatic hypertrophy
o Recurrent gross hematuria
o Renal insufficiency secondary to bladder outlet obstruction
o Bladder calculi
o Permanently damaged or weakened bladders
o Large bladder diverticula that do not empty well secondary to an
enlarged prostate
- Medical Treatment:

Alpha-1-receptor blockers: these provide rapid relief. These drugs block

effects of postganglionic synapses at the smooth muscles and exocrine
glands and relaxes smooth muscle. Tamsulosin (Flomax) is indicated for the
treatment of the signs and symptoms of BPH.
5- Alpha-Reductase Inhibitors: these agents are used to treat symptomatic
BPH in men with enlarged prostate. They inhibit the conversion of
testosterone to DHT, causing DHT levels to drop, which in turn may decrease
prostate size. Dutaseride (Avodart), is indicated for the treatment of BPH as
monotherapy or in combination with Tamsulosin. It improves symptoms,
reduces urinary retention, and may decrease the need for BPH-related
surgery. It inhibits 5-alpha-reductase isoenzymes types I and II and
suppresses conversion of testosterone to DHT causing serum DHT levels to
decrease.
Phosphodiesterase-5-Enzyme Inhibitors: these agents mediate smooth
muscle relaxation in the lower urinary tract, thus improving the symptoms of
BPH. Tadalafil (Cialis) is a PDE5 selective inhibitor and can treat BPH signs
and symptoms. It can induce smooth muscle relaxation in the lower urinary
tract.
Anticholinergic Agents: block the neurotransmitter acetylcholine in the
central and peripheral nervous system. It reduces the effects mediated by
acetylcholine on its receptors in bladder neurons through competitive
inhibition.
d). What is the long term management?
- Patients should be followed up to evaluate the efficacy of the medication and
potential dose adjustment. These visits should take place at least biannually (every 6
months). Patients should undergo DRE & PSA screening at least annually.
e). DDX:

Cystitis
Prostatitis
Ureteral strictures
UTI
Bladder Cancer
Bladder Stones
Foreign bodies in bladder(stones or retained stents)
Neurogenic bladder

3. A 65 year old man presents to the A&E Department with a history of abdominal
pain which radiated to the back and flank and also groin pain. He complains of
having feeling of early satiety, nausea, vomiting. He has a 40 year history of
smoking and chronic obstructive pulmonary disease and HTN. On examination,
you notice he has a fever (101F) and a blue toe.

a). What is the diagnosis? Abdominal Aortic Aneurysm (AAA)

b).Differential diagnosis:

Acute Gastritis
Appendicitis
Cystitis
Diverticulitis
Gallstones(Cholelithiasis)
Large bowel obstruction/Small bowel obstruction
Pancreatitis
MI
Peptic Ulcer Disease

c). Risk factors:

Non-modifiable:
o Age(65 years & older)
o Gender (male)
o Race(more common in Caucasian)
o FHx
o Collagen vascular disease(Ehlers-Danlos syndrome, Marfan
syndrome

Modifiable:
o Tobacco use (smoking, or chewing tobacco)
o Atherosclerosis
o HTN
o Trauma
o Vasculitis(rare)

d). Complications:

Rupture
Death
Peripheral embolization
Pneumonia
MI
Acute aortic occlusion
Aortocaval or Aortodudodenal fistulae

Groin infection
Graft infection
Colonic ischemia
Bowel obstruction
Blue toe syndrome

e). Indications for surgery: The surgery is called AAA Repair and it can be done
Open or by Endovascular aneurysm repair (EVAR) with stent placement.
Elective surgical repair is recommended for aneurysms > 5 to 5.5 cm (when risk
of rupture increases to > 5 to 10%/yr.), unless coexisting medical conditions
contraindicate surgery. Additional indications for elective surgery include
increase in aneurysm size by > 0.5 cm within 6 month regardless of size, chronic
abdominal pain, thromboembolic complications, and an iliac or femoral artery
aneurysm that causes lower-limb ischemia.
- Large aneurysm
-Symptomatic aneurysms
-Ruptured aneurysms
f). Complications of surgery:
Early:
o Hemorrhage, Infection, Damage to surrounding structures,
Thrombosis formation, Death
Late:
o Failure of anastomosis, Failure of graft, Migration of graft, DVT, PE,
Pulmonary complications, Erectile dysfunction, Death
g). Name operative procedures for repair:

Open Repair of AAA

EVAR with stent placement

h). Diagnosis: History & Physical exam

Lab studies: CBC, U&Es, LFTs, Coagulation studies, GXM

Imaging:
o Ultrasonography is the standard imaging tool for AAA, and it can
detect free peritoneal blood.
o Plain ABB Radiograph can show aortic calcification
o CXR for assessment of the status of the heart and lungs.
o CT ABD SCAN, has a high sensitivity (100%), and can define aortic
size, rostral-caudal extent and involvement of visceral arteries and

extension into the suprarenal aorta. It also permits visualization of

the retroperitoneum. It is best for determining whether a patient is a
candidate for EVAR.
o MRI provides better imaging of the branch vessels than CR or USS
but less valuable in assessing suprarenal extension
o Angiography can be used but it is less often used because of CT
scan
o Echocardiography is done to ascertain the ejection fraction of the
heart and is indicated in patients with a history of congestive heart
failure(CHF) or cardiac enlargement
ECG
i). Initial Management: ABC

Admit patient
Airway patent
Breathing give 100% oxygen
Circulation (2-large bore IV,14- 16G)
NPO
Monitor BP, pulse oximetry, temperature
Foley catheter
ABG
ECG
Antiemetics(IV Morphine)
Analgesics
Surgical consult
Patients consent
Book OT

4). A 35 year old woman presents with a lump in her right breast. She is really
concerned because her aunt died from breast cancer at the age of 46 years. On
examination there asymmetry of the breast (Right > Left) is the skin appears
erythematous, and there is tethering of the skin, but no nipple discharge, or Peau d
orange of the skin. On palpation there is a 3cm mass located in RUOQ (Right upper
outer quadrant) of the breast and there is mild tenderness.
a). What is the most likely diagnosis? Breast Cancer
b). How would you manage this patient?
-This patient needs to be managed using the Triple Assessment and this includes;

 History & Clinical physical exam

Mammography or Breast Ultrasound
Core biopsy or FNA
c). Staging: TNM

Stage 0: non-invasive breast cancer; such as DCIS(ductal carcinoma in situ);

cancer cells have not spread to neighboring normal breast tissue
Stage I: Invasive breast cancer(early stage); the tumor <2cm or less and not
spread outside of the breast
o IA: </= 2cm and no spread to lymph nodes
o IB: tumor <2cm with micrometastases in 1 to 2 axillary lymph nodes, but
no spread to distant sites
Stage II: Invasive breast cancer; the tumor is >2cm but not more than 5cm
o IIA: tumor is 2cm or less and has spread to 1 to 2 axillary nodes and to
internal mammary lymph nodes or tumor is >2cm but no spread to LNs
o IIB: tumor >2cm but <5cm and has spread to 1 to 3 axillary LNs and tiny
amounts of cancer found in internal mammy LNs on sentinel LN biopsy
Stage III: Invasive breast cancer; the tumor is >5cm
o IIIA: tumor </= 5cm and has spread to 1 to 9 LNs but no distant spread;
the axillary LNs grows into each other forming clumps(matted together)
OR tumor is >5cm with no adherence of axillary LNs to each other or
other tissues
o IIIB: tumor may be of any size, has spread to LN areas above and
below the clavicle, the chest wall and/or the skin of the breast
Stage IV: tumor of any size but growing into the chest wall or skin; it has
spread to distant areas(metastases), most common sites are liver, lung, brain,
bone
d). Surgical operations: depends on the staging
Stage I & II, local disease is usually treated with;

Breast Conserving Surgery( Lumpectomy) OR

Modified Radical Mastectomy with Sentinel LN biopsy or Axillary LN Dissection
and Chemo +/- Radiation
Depending on the size of the tumor, such as a larger than 2 cm lump Neoadjuvant
therapy (Chemotherapy) will be used first to shrink the size of the tumor and lower the
tumor burden.
Stage II is these are larger tumors>2cm and have spread too few nearby LNs.
Local therapy: Breast Conserving Surgery or Mastectomy with Sentinel LN
biopsy or Axillary LN Dissection. Radiation for large tumors (do before
chemotherapy) and chemotherapy may be needed.
Systemic therapy: Hormone therapy (Estrogen/Progesterone therapyTamoxifen), HER2 targeted drugs (Herceptin), Chemo.

Stage III tumor is >5cm and growing into nearby tissues (the skin over the breast or the muscle
underneath), or cancer has spread too many nearby LNs. Usually treated with neoadjuvant
chemotherapy before surgery.

Mastectomy with axillary LN dissection followed by adjuvant chemotherapy and

hormone therapy and/or HER2 drug, and radiation.
Stage IV is these tumors have spread to distant sites beyond the breast and LN.
Requires Palliative Care.

Systemic therapy is the mainstay of treatment. May consist of Chemotherapy,

hormone therapy, Targeted therapies HER2, or some combinations of these
treatments.
Radiation & Surgery(Mastectomy) may be used in certain situations such as
when the breast tumor is causing an open wound in the breast, to prevent bone
fractures, area of cancer has spread and pressing on the spinal cord, or to
provide relief of pain.
e). What advice would you give this lady who wants to get pregnant in the future?
- The best time to talk with your doctor about fertility is before starting breast cancer
treatment. Because many breast cancers are sensitive to estrogen, there has been
concern that if a woman has been treated for breast cancer, high hormone levels during
pregnancy might increase the chance of the cancer coming back. Studies have shown,
though, that pregnancy does not increase the risk of the cancer coming back after
successful treatment.
Still, many doctors advise breast cancer survivors to wait at least 2 years after all
treatment has finished before trying to get pregnant, though the best length of time to
wait is not clear. Two years is thought to give them the chance to find any early return of
the cancer, which could affect a womans decision to become pregnant. Another
important thing to remember is that chemotherapy for breast cancer also can damage
the ovaries, sometimes causing immediate or delayed infertility.
Each womans decision is based on many things, such as her age, fertility, desire for
more pregnancies, type of breast cancer, risk of an early relapse, and the potential
effect estrogen may have on her risk of a breast cancer coming back. In women with
advanced breast cancer, the treatment usually lasts more than 2 years though and the
person should wait until after treatment to become pregnant. Also, breastfeeding is not
contraindicated after treatment but the chemotherapy drugs used can enter the breast
milk and this can cause side effects in the baby. Such as difficult for the baby to latch
onto the breast.

f). What is Tamoxifen and the side effects?

Tamoxifen is an antagonist of the estrogen receptor in breast tissue via its
active metabolite, 4-hydroxytamoxifen. In other tissues such as the endometrium, it
behaves as an agonist, and thus may be characterized as a selective estrogen-receptor

modulator. Tamoxifen is the usual endocrine (anti-estrogen) therapy

for hormone receptor-positive breast cancer in pre-menopausal women, and is also a
standard in post-menopausal women although aromatase inhibitors are also frequently
used in that setting.
Mechanism of action: competitively binds to estrogen receptors on tumors and other
tissue targets, producing a nuclear complex that decreases DNA synthesis and inhibits
estrogen effects. It is a nonsteroidal agent with potent antiestrogenic properties which
compete with estrogen for binding sites in breast and other tissues. Tamoxifen causes
cells to remain in the G0 and G1 phases of the cell cycle.
Medical uses:

Breast cancer: is currently used for the treatment of both early and advanced
ER+ (estrogen receptor positive) breast cancer in pre- and post-menopausal
women. Also, used to treat male breast cancer.
Infertility: is used to treat infertility in women with anovulatory disorders.
Gynecomastia: is used to prevent estrogen-related gynecomastia, resulting from
elevated estrogenic levels. Especially used in men with prostate cancer who are
treated with estrogens or anti-androgen drugs.

Side effects: The most common are menopausal symptoms including hot flashes,
vaginal dryness, low libido, mood swings, and nausea. It may also cause noncancerous changes in the uterus. In some women, it may increase the risk of blood
clots or endometrial cancer (cancer in the lining of the uterus). It prevents bone loss by
acting as an estrogen receptor agonist , thereby inhibiting osteoclasts, it
prevents osteoporosis. For some women, tamoxifen can cause a rapid increase
in triglyceride concentration in the blood. In addition there is an increased risk
of thromboembolism especially during and immediately after major surgery or periods of
immobility. Tamoxifen is also a cause of fatty liver, otherwise known as steatorrhoeic
hepatosis or steatosis hepatis. It can cause central nervous system effects such as
reduced cognition.
g). What are the risk factors for breast cancer?

Non-modifiable:
o Gender(Female > male)
o Positive FHx of breast cancer
o Genetics (known carrier of BRCA1, BRCA genes)
o Previous history of breast cancer
o Early menarche(before age 12)
o Late menopause(after age 55years)
o First child after age 35 years
o History of other cancers(Endometrial, Colon)
o Race(Blacks have very aggressive cancer)

Modifiable:
o Obesity
o Sedentary lifestyle
o Use of OCP
o Use of hormonal replacement therapy drugs
o Diet(high in fat or high calorie)
o Tobacco use
o Alcohol use