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).
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.
Q) A 73 year male, old heavy smoker presents with haemoptysis. On examination he is cachectic and shows evidence of clubbing. Imaging shows a main bronchial tumour with massive mediastinal lymphadenopathy together with widespread visceral metastases. Which of the following variant is likely in him?
( Theme from mock test 12- 24)
a) Adenocarcinoma
B. Small cell lung cancer
C. Large cell lung cancer
D. Squamous cell carcinoma
Patient: 73-year-old male, heavy smoker
Symptoms: Hemoptysis, cachexia, clubbing
Imaging: Main bronchial tumor with massive mediastinal lymphadenopathy and widespread visceral metastases
Likely Variant:
B. Small cell lung cancer (SCLC) is the most likely diagnosis.
Rationale:
Small Cell Lung Cancer: This type of cancer is strongly associated with heavy smoking and is characterized by aggressive behavior and early metastasis. Most patients present with disseminated disease, as seen in this case.
Clinical Features: The combination of hemoptysis, cachexia, and clubbing aligns well with SCLC, which can also lead to various paraneoplastic syndromes.
Other Tumors:
Adenocarcinoma: More common in never smokers and typically peripheral, not fitting the profile here.
Squamous Cell Carcinoma: Generally grows slower and is also typically centrally located, but not usually associated with such widespread metastasis at presentation.
Large Cell Lung Cancer: While it can be aggressive, it’s less commonly associated with extensive lymphadenopathy and visceral metastases compared to SCLC.
Q) 40 year old lady was on anti thyroid medications which she stopped for 2 weeks. She presented in emergency with high grade fever and hypotension. ( Thyroid Storm) .What is not a part of further management?
Explanation:
In the management of a thyroid storm, radioactive iodine (RAI) is not used. RAI is a predisposing factor for thyroid storm, not a treatment. The management includes beta blockers, oxygen and hemodynamic support, IV Lugol iodine, PTU (propylthiouracil), and corticosteroids.
Q) 45 year old male with road side accident and fracture of 3 ribs on left side. CT scan of the abdomen is shown below. Out of the five grades of splenic injury What is the grade in him ?
Subcapsular haematoma <10% of surface area
Parenchymal laceration <1 cm depth Capsular tear
Grade 2
Subcapsular haematoma 10–50% of surface area; Intraparenchymal haematoma <5 cm
Parenchymal laceration 1–3 cm
Grade 3
Subcapsular haematoma >50% surface area; ruptured subcapsular or intraparenchymal haematoma ≥5 cm Parenchymal laceration >3 cm depth
Grade 4
Any injury in the presence of a splenic vascular
injury or active bleeding confned within the splenic
capsule
Parenchymal laceration involving segmental or hilar
vessels producing >25% devascularisation
Grade 5
Any injury in the presence of splenic vascular injurya
with active bleeding extending beyond the spleen
into the peritoneum – shattered spleen
Vascular injury is defined as a pseudoaneurysm or arteriovenous fistula and appears as a focal collection of vascular contrast that decreases in attenuation with delayed imaging.
Active bleeding from a vascular injury presents as vascular contrast, focal or diffuse, that
increases in size or attenuation in the delayed phase
Pulmonary complications are 57% with TTE 27% with THE ( SKF 409)
Anastomotic leak 16% TTE and 14% THE ( not significant) subclinical leak slightly more in THE
Option D is correct
Cardiac complications, Vocal cord paralysis , wound infection, chyle leak are all more with TTE
Blackmon et al. published a propensity-matched analysis comparing outcomes between side-to-side stapled anastomosis, end-to-end circular stapled anastomosis, and handsewn, with no significant difference in leak rate noted. ( SKF page 475)
