Q) Which of the following patients with operable breast cancer is the most appropriate candidate for preoperative systemic therapy?
A) A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
C) A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
D) A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Correct Answer:B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
Preoperative systemic therapy is generally recommended for:
HER2-positive or triple-negative breast cancer when the tumor is ≥cT2 (≥2 cm) or clinically node-positive (cN1).
Patients with a large tumor relative to breast size who desire breast-conserving surgery.
Patients with clinically node-positive disease (cN+) who may achieve node-negative (cN0) status with systemic therapy.
Option B meets these criteria with both HER2-positive disease and clinically node-positive status, making the patient an ideal candidate for preoperative systemic therapy.
Choice A: A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
Explanation: This patient has an ER-positive, HER2-negative tumor that is small (1 cm) and clinically node-negative. These characteristics indicate a low risk of aggressive disease, and preoperative systemic therapy is typically not necessary for small, low-risk tumors. In this case, surgery would likely be the primary treatment option, followed by adjuvant therapy if needed.
Choice C: A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
Explanation: Although this patient has triple-negative breast cancer (TNBC), the tumor size is only 1 cm and clinically node-negative. Preoperative systemic therapy is generally reserved for larger tumors (≥cT2) or node-positive disease in TNBC cases to improve outcomes or allow breast conservation. In this scenario, with a small, node-negative tumor, the preferred approach might be surgery first, as systemic therapy may not offer substantial additional benefits.
Choice D: A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Explanation: This patient has HER2-positive breast cancer, but the tumor size is only 1.5 cm, which is below the ≥cT2 threshold for recommending preoperative systemic therapy. Additionally, the absence of lymph node involvement (cN0) indicates a lower burden of disease. While HER2-positive patients often benefit from systemic therapy, a neoadjuvant (preoperative) approach may not be necessary unless the tumor or nodal status meets certain thresholds (≥cT2 or ≥cN1).
You've come a long way in your preparation, and now it's time to give it your all. The next 120 days can define your success in the MCH NEET SS exam. Here’s how to make the most of this crucial period:
1. Get Familiar with the Exam Pattern
Before jumping into studying, it’s crucial to know what the exam looks like. NEET SS has multiple-choice questions (MCQs), with negative marking for wrong answers (so guesswork isn’t always your friend). You’ll have 3.5 hours to tackle questions focused on your chosen super-specialty, and most questions are from the postgraduate curriculum. Understanding the structure helps you plan how to approach your studies.
Q) What is the most consistent anatomical landmark of the facial nerve?
A) Anterior border of the posterior belly of the digastric muscle.
B) Posterior border of the posterior belly of the digastric muscle.
C) Superior border of the posterior belly of the digastric muscle.
D) Inferior border of the posterior belly of the digastric muscle.
C) Superior border of the posterior belly of the digastric muscle.
Why This Landmark Matters: The superior aspect of the posterior belly of the digastric muscle serves as a reliable intraoperative landmark for locating the facial nerve. Understanding this landmark can enhance surgical precision and reduce complications.
Key Anatomical Landmarks for Facial Nerve Identification:
Posterior Belly of the Digastric Muscle:
The facial nerve is located about 2 to 4 mm inferior to the tympanomastoid suture line, making the superior border of the posterior belly a consistent guide.
Tragal “Pointer” (of Conley):
The tragal cartilage, found in front of the ear, provides a helpful reference. The facial nerve lies approximately 1 cm deep, slightly anterior and inferior to this point, making it an essential landmark during dissection.
Tendon of the Posterior Belly of the Digastric Muscle:
The attachment of the digastric muscle to the mastoid bone conceals the facial nerve about 1 cm deep. Careful dissection in this area is crucial to uncover this hidden structure.
Tympanomastoid Suture/Fissure:
This area within the temporal bone marks another critical point for identifying the facial nerve, which is situated about 6-8 mm deep.
Styloid Process:
Located laterally to the styloid process, the facial nerve resides in proximity, making it a significant marker during surgical approaches.
Conclusion: Understanding the superior border of the posterior belly of the digastric muscle as the most consistent anatomical landmark of the facial nerve is essential for safe surgical practice. Mastering these landmarks not only enhances surgical outcomes but also promotes patient safety.
Q) After Ivor Lewis esophagectomy, on postoperative day 5 (POD 5), bile is seen in the chest tube. The patient presents with a heart rate of 120 bpm, a temperature of 101°F, and blood pressure of 100/70 mmHg. What is the next appropriate step in management?
a) Stenting b) Colonic replacement of gastric conduit c) IV antibiotics d) Conduit excision and esophageal diversion
Correct Answer:d) Conduit excision and esophageal diversion
Rationale:
In patients who develop a completely necrotic conduit post-esophagectomy, the risk of sepsis is high. These patients often require urgent surgical intervention. Upon confirming conduit necrosis, the conduit must be resected, and the patient should undergo diversion, which includes:
End esophagostomy
Venting gastrostomy
Feeding jejunostomy
It is crucial to maintain as much length of the remaining esophagus as possible to facilitate future reconstructive procedures.
Key Points:
Postoperative Day 5: Critical time for monitoring complications after esophagectomy.
Symptoms of Concern: Tachycardia, fever, and hypotension may indicate sepsis or other complications.
Surgical Intervention: Timely recognition and management are vital for patient outcomes.
For further reading, refer to Schakelford’s Surgical Anatomy of the Gastrointestinal Tract.
