A 19-year-old woman presents to her gynecologist for evaluation of amenorrhea and occasional dull right-sided lower abdominal pain that radiates to the rectum. She had menarche at 11 years of age and had regular 28-day cycles by 13 years of age. She developed menstrual cycle irregularity approximately 2 years ago and has not had a menses for 6 months. She is not sexually active. She does not take any medications. Her weight is 94 kg (207.2 lb) and her height is 166 cm (5.4 ft). Her vital signs are within normal limits. The physical examination shows a normal hair growth pattern. No hair loss or acne are noted. There is black discoloration of the skin in the axillae and posterior neck. Palpation of the abdomen reveals slight tenderness in the right lower quadrant, but no masses are appreciated. The gynecologic examination reveals no abnormalities. The hymen is intact. The rectal examination reveals a non-tender, mobile, right-sided adnexal mass. Which of the following management plans would be best for this patient?

Transvaginal ultrasound should be performed first as it provides superior resolution for adnexal masses, regardless of the patient's sexual history or hymenal status

Pelvic MRI should be the first-line imaging since both transvaginal and transabdominal ultrasound are inappropriate for this virginal, obese patient

Clinical examination is sufficient for diagnosis since the adnexal mass was clearly palpable on rectal examination, making imaging unnecessary

Transabdominal ultrasound is the appropriate first-line imaging for this virginal patient, despite reduced sensitivity due to her obesity, as transvaginal ultrasound would be inappropriate given her intact hymen

The patient's obesity will not significantly affect transabdominal ultrasound quality, so transvaginal ultrasound is unnecessary even though she is virginal

One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show: Hemoglobin 12.5 g/dL Leukocyte count 18,600/mm3 Platelet count 228,000/mm3 Erythrocyte sedimentation rate 120 mm/h Serum Na+ 134 mEq/L K+ 3.5 mEq/L Cl- 98 mEq/L HCO3- 22 mEq/L Glucose 200 mg/dL Urea nitrogen 60 mg/dL Creatinine 3.2 mg/dL Creatine kinase 750 U/L Which of the following is the most appropriate next step in management?

Intravenous clindamycin therapy

X-ray of the abdomen and pelvis

Vacuum-assisted wound closure device

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Upper gastrointestinal endoscopy

A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?

"Can you tell me more about the symptoms you have been experiencing?"

"Does the diarrhea typically precede the constipation, or vice-versa?"

"Is the diarrhea foul-smelling?"

"Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"

"Are the symptoms worse in the morning or at night?"

A 65-year-old man is admitted to the hospital because of a 1-month history of fatigue, intermittent fever, and weakness. Results from a peripheral blood smear taken during his evaluation are indicative of possible acute myeloid leukemia. Bone marrow aspiration and subsequent cytogenetic studies confirm the diagnosis. The physician sets aside an appointed time-slot and arranges a meeting in a quiet office to inform him about the diagnosis and discuss his options. He has been encouraged to bring someone along to the appointment if he wanted. He comes to your office at the appointed time with his daughter. He appears relaxed, with a full range of affect. Which of the following is the most appropriate opening statement in this situation?

What is your understanding of the reasons we did bone marrow aspiration and cytogenetic studies?

Your lab reports show that you have an acute myeloid leukemia

You must be curious and maybe even anxious about the results of your tests.

I may need to refer you to a blood cancer specialist because of your diagnosis. You may need chemotherapy or radiotherapy, which we are not equipped for.

Would you like to know all the details of your diagnosis, or would you prefer I just explain to you what our options are?

A previously healthy 25-year-old woman is brought to the emergency department because of a 1-hour history of sudden severe lower abdominal pain. The pain started shortly after having sexual intercourse. The pain is worse with movement and urination. The patient had several urinary tract infections as a child. She is sexually active with her boyfriend and uses condoms inconsistently. She cannot remember when her last menstrual period was. She appears uncomfortable and pale. Her temperature is 37.5°C (99.5°F), pulse is 110/min, and blood pressure is 90/60 mm Hg. Abdominal examination shows a palpable, tender right adnexal mass. Her hemoglobin concentration is 10 g/dL and her hematocrit is 30%. A urine pregnancy test is negative. Pelvic ultrasound shows a 5 x 3-cm right ovarian sac-like structure with surrounding echogenic fluid around the structure and the uterus. Which of the following is the most appropriate management for this patient's condition?

Emergency exploratory laparotomy

Intravenous methotrexate administration

Oral doxycycline and metronidazole administration

Cytoreductive surgery principles for USMLE Step 2 CK: High-Yield Surgery Lessons

💃 The Debulking Dance

Goal: Surgical removal of maximal visible tumor mass (cytoreduction). Aims to enhance efficacy of subsequent chemotherapy or radiation.
Mechanism: ↓ tumor burden, removes chemo-resistant cores, and ↑ drug penetration into smaller residual nodules.
Key Metric: Residual Disease (RD)
- Optimal: RD < 1 cm. Correlates with improved survival.
- Suboptimal: RD > 1 cm.
Classic Indication: Advanced epithelial ovarian cancer. Also used for peritoneal mesothelioma and pseudomyxoma peritonei.

⭐ The volume of residual disease post-surgery is the most critical prognostic factor in advanced ovarian cancer. The goal is "optimal" debulking (< 1 cm).

Peritoneal Carcinomatosis Index (PCI) regions

🔬 Pathophysiology - Rationale & Indications

Core Rationale: To surgically reduce the macroscopic tumor burden ("debulking"). This enhances the efficacy of subsequent systemic or regional chemotherapy (e.g., HIPEC).
Mechanism: Smaller residual tumor volume allows for better drug penetration, targets rapidly dividing cells, and decreases the likelihood of developing resistant clones.
Primary Indications: Peritoneal surface malignancies where disease is confined.
- Ovarian Cancer
- Pseudomyxoma Peritonei
- Peritoneal Mesothelioma
- Select Colorectal & Appendiceal Cancer with peritoneal mets

⭐ The goal is complete cytoreduction (CC-0), leaving no visible residual disease. This is the single most important prognostic factor for survival.

🎯 Patient Selection Criteria

Physiologic Fitness:
- Good performance status (ECOG 0-1).
- No severe comorbidities; able to tolerate major surgery.
Tumor Biology:
- Favorable histology (e.g., low-grade appendiceal, mesothelioma).
- Chemo-sensitive disease.
Disease Extent & Resectability:
- Low volume of disease (low Peritoneal Cancer Index - PCI).
- No extensive/unresectable extra-abdominal metastases.
- No deep parenchymal liver/lung metastases.

⭐ The goal of CRS is complete cytoreduction (CC-0/CC-1), leaving no or minimal (<2.5 mm) residual disease. The Peritoneal Cancer Index (PCI) score is critical for predicting resectability.

Peritoneal Cancer Index (PCI) scoring and staging

🔪 CRS + HIPEC Technique

Goal: A two-pronged attack to eradicate macroscopic (CRS) and microscopic (HIPEC) peritoneal disease.
Procedure Steps:
1. Cytoreductive Surgery (CRS): Meticulous surgical removal of all visible tumor implants (peritonectomy, organ resections).
2. HIPEC: Intraoperative "chemo bath" with agents like Mitomycin C or Cisplatin, heated to 41-43°C and circulated for 60-90 minutes.
  - Heat enhances drug penetration and provides direct cytotoxic effects.

⭐ The single most important prognostic factor for long-term survival is the Completeness of Cytoreduction (CC score). A CC-0 score (no visible residual disease) is the goal.

HIPEC: Open vs. Closed Technique Catheter Placement

⚠️ Complications - The Price of Progress

High morbidity (30-50%) & mortality (2-5%) risk; correlates with procedural extent (PCI) and patient comorbidities.
GI: Prolonged ileus, anastomotic leak, enterocutaneous fistula, pancreatitis, chyle leak.
Systemic: High risk of VTE (DVT/PE), ARDS, AKI, sepsis/SIRS.
HIPEC-Specific: Profound myelosuppression (neutropenia), electrolyte abnormalities (↓Mg, ↓K), renal toxicity.

⭐ Anastomotic leak is a major driver of mortality. Suspect with fever, tachycardia, and leukocytosis around post-op day 5-7.

CT: Extraluminal air & fluid, anastomotic leak

⚡ Biggest Takeaways

Cytoreductive surgery (CRS), or debulking, aims to remove all gross visible tumor, not for cure but to improve efficacy of subsequent therapy.

The primary goal is "no gross residual disease" (R0/R1 resection); R2 resection (visible tumor left) has poor outcomes.

Completeness of cytoreduction is the single most important prognostic factor for survival.

Commonly used for peritoneal surface malignancies like ovarian cancer and pseudomyxoma peritonei.

Often combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

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