Patient 1 – A 26-year-old woman presents to her primary care physician for an annual exam. She currently does not have any acute concerns and says her health has been generally well. Medical history is significant for asthma, which is managed with an albuterol inhaler. Her last pap smear was unremarkable. She is currently sexually active with one male and consistently uses condoms. She occasionally smokes marijuana and drinks wine once per week. Her mother recently passed away from advanced ovarian cancer. Her sister is 37-years-old and was recently diagnosed with breast cancer and ovarian cancer. Physical examination is remarkable for a mildly anxious woman. Patient 2 – A 27-year-old woman presents to her primary care physician for an annual exam. She says that she would like to be screened for breast cancer since two of her close friends were recently diagnosed. She noticed she has a small and mobile mass on her left breast, which increases in size and becomes tender around her time of menses. Family history is remarkable for hypertension in the father. The physical exam is significant for a small, well-defined, and mobile mass on her left breast that is not tender to palpation. Which of the following is the best next step in management for patient 1 and 2?

Patient 1 – BRCA testing. Patient 2 – Breast ultrasound

Patient 1 – Breast ultrasound. Patient 2 – Return in 3 months for a clinical breast exam

Patient 1 – Reassurance. Patient 2 – Breast ultrasound

Patient 1 – CA-125 testing. Patient 2 – BRCA testing

Patient 1 – Breast and ovarian ultrasound. Patient 2 – Mammography

A 68-year-old man presents with a 3-month history of difficulty starting urination, weak stream, and terminal dribbling. The patient has no history of serious illnesses and is not under any medications currently. The patient’s father had prostate cancer at the age of 58 years. Vital signs are within normal range. Upon examination, the urinary bladder is not palpable. Further examination reveals normal anal sphincter tone and a bulbocavernosus muscle reflex. Digital rectal exam (DRE) shows a prostate size equivalent to 2 finger pads with a hard nodule and without fluctuance or tenderness. The prostate-specific antigen (PSA) level is 5 ng/mL. Image-guided biopsy indicates prostate cancer. MRI shows tumor confined within the prostate. Radionuclide bone scan reveals no abnormalities. Which of the following interventions is the most appropriate next step in the management of this patient?

Radiation therapy + androgen deprivation therapy

Chemotherapy + androgen deprivation therapy

Radical prostatectomy + chemotherapy

Radical prostatectomy + radiation therapy

A 43-year-old woman presents to your clinic for the evaluation of an abnormal skin lesion on her forearm. The patient is worried because her mother passed away from melanoma. You believe that the lesion warrants biopsy for further evaluation for possible melanoma. Your patient is concerned about her risk for malignant disease. What is the most important prognostic factor of melanoma?

Depth of invasion of atypical cells

Level of irregularity of the borders

A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?

Surgical evacuation of the clots

Administration of levetiracetam

Administration of methylprednisolone

Minimally invasive oncologic surgery for USMLE Step 2 CK: High-Yield Surgery Lessons

🔑 Keyhole Cancer War: Minimally Invasive Oncologic Surgery

Minimally Invasive Surgery (MIS) uses laparoscopy or robotics for cancer resection via small incisions.

Patient Benefits: ↓ post-op pain, ↓ blood loss, ↓ hospital stay, faster recovery, better cosmesis.
Oncologic Mandates: Must adhere to the same principles as open surgery:
- Complete tumor removal with negative margins (R0).
- Adequate lymph node dissection.
- Strict avoidance of tumor spillage.
Key Risks:
- ⚠️ Port-site metastasis: A major concern if poor technique leads to tumor seeding.
- Loss of tactile feedback; longer initial operative times.

⭐ For many cancers (e.g., colorectal, prostate, endometrial), MIS offers equivalent long-term oncologic outcomes (survival) compared to open surgery, but with superior short-term recovery profiles.

Laparoscopic port placement and surgical setup

🤖 Management - The Good, Bad, & Robotic

Laparoscopic ("The Good"):
- - Benefits: ↓ pain, ↓ blood loss, ↓ hospital stay, faster recovery, improved cosmesis.
- - Goal: Achieve same oncologic outcomes as open surgery (en-bloc resection, negative margins, adequate lymphadenectomy).
Challenges ("The Bad"):
- - Limitations: Loss of haptic (tactile) feedback, 2D vision, steep learning curve.
- - ⚠️ CO₂ Insufflation: Can cause hypercarbia, acidosis, and ↓ venous return. Caution in patients with severe cardiopulmonary disease.
- - Port-site Metastasis: Historically a concern; now rare with specimen retrieval bags.
Robotic ("The Robotic"):
- - Advantages: 3D magnified vision, wristed instruments (7 degrees of freedom), tremor filtration.
- - Best Use: Complex dissection in confined spaces (e.g., prostatectomy, low anterior resection).
- - Downside: ↑ cost, longer setup time.

⭐ For many cancers (e.g., colon, prostate, endometrial), MIS offers equivalent long-term oncologic outcomes (survival) to open surgery, with improved short-term morbidity.

Robotic surgical system components

⚠️ Complications - Tiny Incisions, Big Concerns

Port-Site Metastasis (PSM):
- Tumor cell implantation at trocar sites.
- Mechanisms: Direct contamination during specimen extraction, aerosolization of tumor cells ("chimney effect" with CO₂ leakage).
- Prevention: Use of specimen retrieval bags, minimizing tumor manipulation.
Gas-Related (CO₂ Insufflation):
- Gas Embolism: Rare but fatal. Sudden ↓ETCO₂, hypotension, "mill-wheel" murmur.
- Subcutaneous Emphysema: Usually benign; resolves spontaneously.
- Pneumothorax/Pneumomediastinum: Risk in upper abdominal/thoracic cases.
Access & Instrument Injuries:
- Trocar Injury: Vascular (e.g., epigastric artery) or visceral (bowel) damage.
- Thermal Injury: Unrecognized burns from electrocautery.

⭐ Port-site metastasis (PSM) is a unique, feared complication that challenges the oncologic safety of MIS. Proper technique, including specimen containment, is critical to prevention.

🤏 When to Go Small

The decision for Minimally Invasive Surgery (MIS) hinges on achieving oncologic goals with less morbidity.

Core Principle: MIS is an option only when it achieves the same oncologic outcome (R0 resection, adequate nodes) as open surgery.
Favorable Factors:
- Tumor: Early-stage, localized, non-bulky.
- Patient: Significant comorbidities, obesity.
Contraindications:
- Bulky/invasive disease.
- High risk of tumor spillage.
- Hemodynamic instability.
- Inadequate surgeon experience.

⭐ The key is oncologic non-inferiority. MIS must match open surgery's survival rates before its benefits (↓ pain, ↓ length of stay, faster recovery) make it the preferred approach.

Open, Laparoscopic, and Robotic Surgery Incisions

⚡ Biggest Takeaways

MIOS (laparoscopic/robotic) must achieve equivalent oncologic outcomes (survival, margins) to open surgery.

Major benefits include ↓ pain, ↓ blood loss, shorter hospital stays, and faster recovery.

Key risks involve a steep learning curve, longer operative times, and loss of tactile feedback.

Port-site metastasis is a rare complication, mitigated by using specimen retrieval bags.

Strict adherence to oncologic principles-en bloc resection, negative margins, and adequate lymphadenectomy-is paramount.

CO2 pneumoperitoneum can cause hypercarbia and increased intracranial pressure.

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