Devita, Hellman, and Rosenberg's Cancer

LWBK1006-20 LWW-Govindan-Review December 12, 2011 19:4

254 DeVita, Hellman, and Rosenberg’s CANCER: Principles and Practice of Oncology Review

Question 20.3.8. A 66-year-old man is noted to have painless jaundice on a routine follow-

up at his primary care physician’s office. Workup reveals biliary obstruc-

tion at the hilum. Endoscopic retrograde cholangiopancreatography con-

firms a high-grade stricture predominantly involving the left hepatic duct;

however, brushings reveal atypical cells and no malignancy. He is seen at

a tertiary care center and offered surgical management, an en bloc resec-

tion of the left hepatic lobe and extrahepatic bile duct, and a complete

periportal lymphadenectomy. Which of the following statements about

management/natural history of hilar cholangiocarcinoma is/are TRUE?

A. Surgical resection is associated with an operative mortality rate of

30%.

B. Recurrences occur most commonly at the bed of resection, followed

by retroperitoneal lymph nodes. Distant metastases occur in one-third

of cases.

C. Less than 10% of patients have resectable cancer at the time of diag-

nosis.

D. All of the above.

Question 20.3.9. A 70-year-old man presents to an emergency department with a history of

16-lb recent weight loss and persistent right upper quadrant pain. CT scan

reveals a gall bladder stone and thickening of the anterior wall of the gall

bladder. He undergoes a laparoscopic cholecystectomy. Pathology reveals

a moderately differentiated 2-cm gall bladder adenocarcinoma invading

the perimuscular connective tissue. Margins of resection are negative for

tumor. What is the stage of this cancer?

A. Stage IA

B. Stage IB

C. Stage IIA

D. Stage IIB

Question 20.3.10.The patient in Question 20.3.9 recovers after his surgery and receives a

second opinion at a tertiary care center 5 weeks after his cholecystectomy.

A follow-up CT scan 2 weeks after surgery shows mild periportal fullness.

What would be the best approach at this time?

A. Perform en bloc resection of the gallbladder, resection of segments

IVb and V of the liver, and regional lymph node dissection.

B. No further therapy is warranted; surveillance with CT scans and

laboratories done every 3 months.

C. He requires a second laparotomy to assess the extent of remaining

disease to guide further therapy.

D. Perform ultrasound-guided biopsy of the periportal nodes; if positive,

then fluoropyrimidine-based chemoradiation is indicated.