General Surgery Board Review Case Studies & Practical Application 4 — Questions and Answers
Question 1: A 30-year-old male presents with a painless right testicular mass. Serum AFP is markedly elevated. CT shows retroperitoneal lymphadenopathy. Orchiectomy is planned. What is the most likely diagnosis?
- Pure seminoma
- Yolk sac tumor (non-seminomatous GCT) (Correct answer)
- Lymphoma
- Leydig cell tumor
Correct answer: Yolk sac tumor (non-seminomatous GCT)
Markedly elevated AFP is diagnostic of non-seminomatous germ cell tumor (NSGCT), as pure seminoma does not produce AFP.
Question 2: A 62-year-old male undergoes emergent sigmoid colectomy with Hartmann's procedure for perforated diverticulitis. Six months later, he is healthy with a colostomy. What is the next appropriate step?
- Permanent colostomy — no further surgery indicated
- Colostomy reversal (Hartmann's reversal) with colorectal anastomosis (Correct answer)
- Ileostomy creation to protect a future anastomosis
- Low anterior resection with diverting loop ileostomy
Correct answer: Colostomy reversal (Hartmann's reversal) with colorectal anastomosis
After recovery from Hartmann's procedure for diverticulitis, restoration of bowel continuity via Hartmann's reversal is appropriate in a fit patient.
Question 3: A 48-year-old woman has a 2 cm solid pancreatic tail mass found incidentally on CT. EUS-FNA shows cells consistent with a pancreatic neuroendocrine tumor. Octreotide scan shows no distant metastases. What is the recommended treatment?
- Observation with serial imaging
- Distal pancreatectomy and splenectomy (Correct answer)
- Systemic chemotherapy with streptozocin
- Enucleation alone
Correct answer: Distal pancreatectomy and splenectomy
Resectable non-functional pancreatic NETs ≥2 cm should be surgically resected; distal pancreatectomy with splenectomy is standard for tail lesions.
Question 4: A 55-year-old male with alcoholic cirrhosis (Child-Pugh B) presents with a 3 cm HCC on imaging. AFP is 450. CT shows no portal vein invasion or distant metastases. He is not a transplant candidate. What is the best local treatment option?
- Surgical resection
- Radiofrequency ablation (RFA) (Correct answer)
- Transarterial chemoembolization (TACE)
- Sorafenib
Correct answer: Radiofrequency ablation (RFA)
In cirrhotic patients who are not surgical candidates, RFA is preferred for HCC ≤3 cm with excellent local control rates comparable to resection.
Question 5: A 38-year-old woman presents with a palpable 2.5 cm right breast mass. Core biopsy shows invasive ductal carcinoma, ER+/PR+/HER2-. Sentinel lymph node biopsy shows 1/3 nodes positive (micrometastasis 0.4 mm). What is the next best step for axillary management?
- Completion axillary lymph node dissection
- Axillary radiation alone
- No further axillary surgery — observe with radiation (Correct answer)
- Level III axillary dissection
Correct answer: No further axillary surgery — observe with radiation
Per Z0011 trial criteria, patients with 1-2 positive sentinel nodes undergoing breast-conserving surgery and whole-breast radiation do not benefit from completion ALND.
Question 6: A 70-year-old male develops sudden onset bright red blood per rectum with hemodynamic instability. Colonoscopy cannot localize the source due to blood. CT angiography shows active bleeding from the right colon. Angiographic embolization fails. What is the next step?
- Segmental right hemicolectomy (Correct answer)
- Total abdominal colectomy with ileostomy
- Repeat colonoscopy after prep
- Vasopressin infusion and observation
Correct answer: Segmental right hemicolectomy
When angiographic embolization fails and the bleeding source is localized to the right colon on CT angiography, segmental right hemicolectomy is appropriate.
Question 7: A 44-year-old woman presents with hypercalcemia (Ca 11.8), fatigue, and kidney stones. Labs show elevated PTH and low phosphorus. Sestamibi scan shows a single hyperfunctioning right inferior parathyroid gland. What is the recommended operation?
- Four-gland bilateral parathyroid exploration
- Minimally invasive parathyroidectomy (focused exploration) (Correct answer)
- Total parathyroidectomy with autotransplantation
- Medical management with cinacalcet
Correct answer: Minimally invasive parathyroidectomy (focused exploration)
A clearly localized solitary adenoma on sestamibi scan is best managed with minimally invasive targeted parathyroidectomy, confirmed by intraoperative PTH drop >50%.
General Surgery Board Review Case Studies & Practical Application 4
A 30-year-old male presents with a painless right testicular mass.
Serum AFP is markedly elevated.
CT shows retroperitoneal lymphadenopathy.
Orchiectomy is planned.
What is the most likely diagnosis?