BiRADS classification

0: incomplete assessment
1: negative (normal breast)
2: benign finding
3: likely benign finding (short-interval follow-up suggested)
4: suspicious finding (biopsy suggested)
5: highly suspicious of malignant finding

Branches of External Carotid Artery

"Sally Ann Likes Flirting On Philadelphia's Main Street"
- Superior thyroid
- Ascending pharyngeal
- Lingual
- Facial
- Occipital
- Posterior auricular
- Maxillary
- Superficial temporal

GIST Metastatic Risk Criteria

Gastrointestinal Stromal Tumors (GIST)

- Can arise from any mesenchymal component of gastric wall (hence previous designation of leiomyoma/leimyosarcoma)
- 3% of all gastric malignancies
- 50% of GIST in the stomach
- Carney triad: nonhereditary syndrome in young females (children) - gastric GIST, paraganglioma, pulmonary chondroma.
- increased incidence of GIST in pts with NF1
- Main route of metastasis is hematologic.  Lymphatic dissemination rare (<10%) therefore extensive lymphadenectomy not indicated
- presentation will largely depend on whether mass enalrges intraluminally or extraluminally

Metastases:
- 50% present with mets
- metastases can present as multiple serosal nodules throughout the peritoneal cavity or nodules in the liver. Extra-abdominal mets are rare.

Diagnosis:
- needle biopsy is not indicated, risks seeding or tumor rupture: soft and fragile tumor
- ? if unresectible then perhaps consider biopsy to justify upfront imatinib ?make the lesion resectable
- low risk metastases: <5cm, <5 mitoses/50 HPF

Pathology:
- Firm gray-white masses.
- often have a pseudocapsule that separates tumor from normal smooth muscle
- 80% have gain of function mutation of tyrosine kinase c-KIT, 8% have mutation that activates tyrosine kinase PDGFRA
- common stem cell - interstitial cells of Cajal

Adjunctive Therapy:
- NOT radiosensitive
- traditional chemo does not improve survival
- Imatinib: small molecule inhibitor of c-kit receptor

Survival:
- 5 year survival is 42% with complete resection
- survival drops to 9% with incomplete resection (?pre-Gleevec era)

Williams Tracheostomy

Supplies.
Headlamp
Cautery
Extra retractors - Langenbach
Split drape
Dentals

Position pt with roll transversely across shoulders
Prep neck
Setup instruments and prepare dental rolls

STEPS:
- Transverse skin incision
- "Defat" wound
- Place langenbach retractors in wound and incise linea alba with catery
- Dissect down to thyroid capsule
- Try to retract thyroid gland away and off of trachea or else go through it slowly with cautery
- Use dentals to push of pretracheal fascia
- Make transverse incision along inter ring space
- Cut/strech with mets, retractors
- Insert tube inflate cuff , secure in place with neck strap then place gauze.

- Posted from iPhone

Williams post op thyroid hypocalcemia

Calcium carbonate 1 g po tid
Rocalcitrol 0.25 mg po bid x 2 week
Syntheoid .1 mg po qd x 8 wkd
Fu 6 wkd
Ca pth qtues and Thursday
Check tsh in 5 weeks



- Posted from iPhone

Differential Parotid gland masses

Benign:
- Pleimorphic adenoma
- Warthin's tumor
- Oncocytoma
- Basal cell adenoma
- hemangioma
- myeloepithelioma

Malignant:
- Mucoepidermoid ca
- Adenoid cystic ca
- Adenoca
- mixed malignant (malignant transformation of pleimorphic adenoma (10% over 15 years))
- Acinic cell ca
- squamous cell ca
- Mets
- Lymphoma
- Sarcoma