Surgical Oncology
Core concepts
Oncology questions emphasize staging, margin principles, and multidisciplinary decision-making. Know TNM staging concepts, the role of sentinel lymph node biopsy in melanoma and breast cancer, and the principle that oncologic resection aims for negative margins with adequate lymph node evaluation. Understand neoadjuvant versus adjuvant therapy rationale and the importance of multidisciplinary tumor boards.
Traps
- Sentinel node biopsy: appropriate in clinically node-negative disease for staging; a positive sentinel node may change management but does not always mandate completion dissection.
- Margins: a positive margin generally indicates re-excision in most solid tumors; the definition of adequate margin varies by tumor type.
- Neoadjuvant vs. adjuvant: neoadjuvant therapy is used to downstage tumors before surgery; don't confuse timing.
- Colorectal cancer: lymph node harvest and margin status affect staging and prognosis; questions test whether you recognize the importance of adequate nodal sampling.
Rule of thumb
Stage first, then treat. For most solid tumors, accurate staging determines whether surgery is primary therapy or follows neoadjuvant treatment, and multidisciplinary discussion guides sequencing.
Worked example
A patient with a colon mass and no distant disease: stage with CT and consider the role of nodal assessment. Oncologic resection includes adequate lymph node harvest; adjuvant chemotherapy follows based on final stage.
Trauma
Core concepts
Trauma questions test the primary survey (ABCDE), hemorrhage control, and the decision between operative and nonoperative management. Understand the role of focused assessment with sonography for trauma (FAST), CT in the stable patient, and damage-control principles in the unstable patient. Know the presentation of tension pneumothorax, hemothorax, cardiac tamponade, and solid organ injury.
Traps
- Stable vs. unstable: the unstable patient with a positive FAST or peritonitis goes to the operating room; the stable patient can be evaluated with CT. Don't order CT on an unstable patient.
- Tension pneumothorax: a clinical diagnosis-decompress immediately with needle thoracostomy followed by tube thoracostomy; do not wait for imaging.
- Cardiac tamponade: Beck's triad (hypotension, muffled heart sounds, distended neck veins) and pulseless electrical activity should prompt consideration of pericardiocentesis or thoracotomy.
- Damage control: in the severely injured patient, prioritize hemorrhage control and temporary closure, then return for definitive repair after physiologic stabilization.
Rule of thumb
Treat the patient, not the scan. In an unstable trauma patient, the operating room or immediate intervention takes priority over imaging.
Worked example
A hypotensive patient after blunt abdominal trauma with a positive FAST: proceed to laparotomy for hemorrhage control. If coagulopathy and hypothermia develop, apply damage-control principles and plan staged repair.