11/5 tracy GI

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11/5 tracy GI
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  1. The ____ is a straight collapsable tube about 25cm (10inches) long that functions as a passageway through the thorax.
    esophagus
  2. the esophagus begins at the base of the pharynx at the level of ____ and descends behind the _____, passing through the mediastinum.
    • C6
    • trachea
  3. THe esophagus penetrates the diaphragm through an opening called the _____ _____, and it is comtinous with the stomach on the abdominal side of the diaphragm.
    esophageal hiatus
  4. The esophagus is inclose proximity  of the ____ and the trachea and can be divided into various areas.
    aorta
  5. The cervical esophagus is about 5cm long and extends from the level of ___ to the level of ____.
    C6 & T1
  6. Below the cervical esophagus is the ____ esophagus
    thoracic
  7. In addition to the cervical & thoracic divisions, the esophagus can also be broken arbitrarily into an ____ third, a ____ third, and a ____ third.
    • upper
    • middle
    • lower
  8. Cancers are the least common in the ____ third and most common in the ___ or ___ third of the esophagus.
    • least common = upper
    • most common= middle or lower third
  9. The lymphatic drainage of the esophagus is unpredictable and there are a large number of widely seperated collections of lymph nodes.  Drainage does not always follow a contiguous pattern; a distance of as much as 8cm of normal esophagus may be interposed between the site of gross tumor and lymphatic metastases.
  10. When you start trying to measure where the espohageal tumor is - start counting at the ______.
    incisiors
  11. Esophageal cancer is ____% of all cancer

    Esophageal cancer is ____% of all cancer deaths in the US
    1%

    2%
  12. Men are  __ to __ times more affected than women.
    3 to 4
  13. African Americans are ___% more likely to get esophageal cancer than whites
    50%
  14. The most common age of diagnosis of esophageal cancer is ___ - ___.
    55 to 85
  15. Esophageal cancer is greater in frequency in Northern ____, northern ____ and South _____.
    • northern china
    • northern iran
    • south africa
  16. Incidence & Etiology (Causes of Esophageal Cancer)
    • Alcohol & Tobacco use
    • Chemical Exposure
    • Barrett's esophagus
    • Achalasia
    • Plummer-Vision Syndrome
  17. Esophageal
    What do people commonly complain of upon clinical presentaion?
    • Dysphagia
    • Chest pain
    • Regurgitation & aspiration
    • Odynophagia
    • Hematemesis
    • Coughing
    • Hemoptysis
    • Hoarseness
  18. Define Dysphagia
    difficulting swallowing
  19. Define Odynophagia:
    painful swallowing
  20. Define Hematemesis
    vomitting up blood
  21. Define hemoptysis
    spitting up blood
  22. What are some different teset used to detect esophageal tumors
    • Chest x-ray
    • barium swallow
    • Pet/Ct
    • Esophagoscopy
  23. Esophageal Tumor Locations:
    ___ - ___ are located in the middle third
    ___ - ___ are located in the lower third
    ___ - ___ are located in the upper third
    • 40% to 50%
    • 25 -50
    • 10 - 25
  24. With esophageal cancer what is the most common pathology (in upper & middle)
    squamous cell


    At the beginning of the esophagus it is squamous cell once you pass the gastroesophageal it becomes  adenocarcinomas until you reach the anus
  25. What does it mean when staging is based on extension outward
    it is staged by how many layers it has invaded.`
  26. What are the routes of spread of esophageal cancers?
    • Lymphatic (submuscosal spread)
    • Local invasion
    • Distant Metastasis
  27. What is the primary site of metastasis of esophageal cancer?
    Liver
  28. what are the main sites of metastasis of esophageal cancer?
    Liver, lung, bone, adrenals & brain
  29. What are adrenals?
    Adrenals are littel glands that sit atop the kidneys
  30. What are treatment techhniques of esophageal cancer?
    • surgery - if possible.
    • radiation therapy
    • chemotherapy
  31. When is surgery for esophageal cancer appropriate?
    • when the tumor is in the middle & lower third only.
    • Usually reserved for small and non-metastatic lesions
  32. What are some complications of surgery for esophageal cancers?
    • anastomotic leaks
    • PE (Pulmonary Emblem blood clot)
    • myocardial infarction
    • strictures
    • GE reflux
  33. What are the 2 most common chemotherapy drugs used for esophageal cancer?
    • 5 FU
    • Cisplatin
  34. Remember because it has submuscosal spread the fields are large
  35. Esophageal Radaitoin Therapy:

    All lesions have a ___cm margin superior and inferior and __-__cm laterally
    • 5cm
    • 2-3cm
  36. Lesions of the ___ third are treated with a field that begins at the level of the thyroid cartilage and end at the level of the ____ to include any scv nodes, low anterior cervical and mediastinal nodes.
    • upper
    • carina
  37. Lesions of the ____ third are treated with fields that include the mediastial nodes and the celiac axis
    lower
  38. Lesions in ___ third include ther periesophageal and medistinal nodes
    mid
  39. In esophageal radiation therapy _____ fields are used to treat the initial large fields followed by shrinking fields.
    AP/PA
  40. Boost fields can be done with a 3 field technique (____ and 2 posterior obliques), Obliques, Laterals or ____) 
    • AP
    • IMRT
  41. What is the patient positioning during esophageal radiation therapy?
    • supine with arms by side or over head
    • or
    • prone with arms above head
  42. What is the esophageal radiation alone dose?
    6500 cGy with offcord at 3600 - 4500 cGy
  43. What is the esophageal radiation doses with chemotherapy?
    5040 cGy with off cord at 3600 - 4500 cGy
  44. What are the critcal structures involved when givinig radiation to the esophagus?
    Lungs, heart, and spinal cord
  45. What are side effects of radiation to the esophagus?
    • esophagitis
    • ulceration of the esophagus
    • decreased blood counts
    • radiation pneumonitis
    • pericarditis
    • perforation of the esophageal-treachea wall
    • strictures
    • transverse myelitis
  46. what is the #1 side effect of radiation to esophagus?
    esophagitis
  47. what is pericarditis
    inflammation of heart muscles
  48. what is transverse myelitis
    severed spinal cord
  49. What is the most important digestive enzyme?
    pepsin
  50. There are greater incidence in ____, ____, & ____ of stomach cancer than inthe United States
    • Japan
    • Chile
    • Iceland
  51. Stomach cancer:
    Incidence is higher in _______ americans and _____ americans
    african & native
  52. Stomach cancer is 2:1 more common in _____
    men
  53. What is the peak age of stomach cancer diagnosis?
    50 - 70
  54. Stomach cancer is ___% adenocarcinoma.

    the other 10% include lymphoma, squamous cell and leimomyosarcoma (smooth muscle)
    90
  55. In stomach cancer ____% of lesions are found in the distal portion
    ___% in the cardiac region
    ___% in the greater curvature, and
    __ - ___% in the entire stomach
    • 50%
    • 25%
    • 5%
    • 10-15%
  56. If the entire stomach is involved it will be a ______ not an adenocarcinoma
    lymphema
  57. What are some risk factors (etiology) for stomach cancer?
    • Diet (red meat)
    • Coal mining
    • Blood type (A)
    • Rubber working
    • Asbestos exposure
    • Gastric ulcers/polyps
    • Alcohol/tobacco
    • Poor nutrition
    • Inadequate sanitation of consumable
    • H. pylori (bacteria than live in the stomach acid)
  58. What are some symtoms of stomach cancer?
    • persistent indigestion
    • epigastric distress or pain
    • loss of appetite
    • weight loss
    • nausea & vomitting
    • Dysphasia
    • jaundice
    • abdominal mass or bloating
  59. stomach tumors are diagnoised on physical exam, upper gi series, ct & endoscopy
  60. what does the work up for stomach cancer consist of?
    • CBC (most have anemia)
    • Guaiac stool test
    • Upper GI
    • Endoscopy with biopsy
    • CT scan of chest and abdomen
    • Laparoscopy
  61. What is the staging system of stomach cancer?
    TNM
  62. _______ have distanct mets at diagnosis
    1/3
  63. what does anastomosis mean?
    leaks
  64. what is the 5 year survival rate of stomach cancer?
    10%
  65. Spread patterns of stomach cancer:
     Lymphatics -
          greater & lesser curvature, splenic, celiac, and haptic nodes
  66. Spread patterns of stomach cancer:
    Direct -
       Bowel, omenta, pancreas, colon, regional nodes
  67. spread patterns of stomach cancers:
    Blood -
       Liver & Lung
  68. When is surgery possible for treating stomach cancer?
    when no mets is present
  69. what are some complications of surgery for stomach cancer?
    • infection
    • hemorrhage
    • anemia
    • anastomosis
    • PE
  70. Radiatioon therapy for stomach cancer:
    AP/PA - Fields extends from diaphragm to L3 including duodenal loop and regional lymph nodes
  71. What is the curative dose for stomach cancer?
    5000-5500 cGy
  72. What is the Pallative dose for stomach cancer?
    3500-4000 cGy
  73. What is the dose for Gastric Lymphomas?
    4000 cGy
  74. What are side effects of radiation therpay when treating stomach ca?
    • ulcers
    • fistula
    • decreased blood counts
    • bowel obstruction
    • and transverse myelitis
  75. what are the critcial structures to be concerned with when giving radiation therapy to the stomach ca?
    • kidneys
    • liver
    • bowels
    • spinal cord
  76. What position should the patient be in for rad. therapy of the stomach?
    supine with arms over head
  77. In the small intestine cancers are rarely ______
    carcinoma
  78. In the small intestine tumors are usually located in the _____ or first few jujunal lesions.
    duodenum
  79. ___% of all small intestine lesions are adenocarcinomas

    Lymphoma, carcinoids and sarcomas make up the rest
    50%
  80. You do not treat the small intestine with radiation because the small bowel is constantly moving
  81. Once cancer of the small intestine moves into the blood stream it normally goes straight to the ____
    liver
  82. What are some symtoms of small intestine cancer?
    • Obstruction
    • rectal bleeding
    • weight loss
    • weakness
    • bloating
    • abbdominal pain
    • N & V
    • fever
    • change in bowel habits
  83. Small Intestine disease can spread by direct extension, ____ or blood system to _____, lungs and bone
    lymph

    liver
  84. _____ ______ disorders include polyposis, Crohn disease, and Gardner's syndrome
    small intestine
  85. What are treatment options for small intestine disease?
    • Surgery
    • Chemotherapy ( 5 FU )

    with no role for radiation therapy due to the bowel sensitivity and motion of the organ
  86. what is the 5 year survival rate for small intestine?
    less than 20%
  87. Large intestine cancer is ranked ____ in the US for men & women in incidence and ____ for overall death rates
    3rd

    2nd
  88. peak age  for large intestine diagnosis is ____ or older
    50
  89. _______ lesions are most common in large intestine cancer
    rectal
  90. causes of large intestine cancer are:
    • diets high in fat
    • diets low in fiber
    • obesity
    • smoking
    • alcohol
    • minimal physical activity
    • familial polyposis
    • chronic ulcerative colitis
  91. What is the # 1 symptom of large intestine cancer?
    blood in stool
  92. Define tenesmus. (large Intestine)
    ractal spasms
  93. define hematochezia
    rectal bleeding
  94. What are some symptoms of Large Intestine Cancer?
    • Blood in stool
    • rectal bleeding (hematochezia)
    • Change in bowel habits
    • Pencil stools
    • tenesmus (rectal spasms)
    • N & V
    • Obstruction
  95. How is large intestine cancer detected & diagnosed?
    • physical exam
    • radiographic & endoscopic studies
  96. How is staging done for Large Intestine Cancer?
    TNM classification or the Dukes classification (A, B,C)
  97. All staging classifications are explaining the penetration of the tumor through the layers of the bowel wall

    (Large Intestine)
  98. What are some of the routes of spread in Large Intestine Cancer?
    Direct extension (penetrates bowel wall, not longitudinally      like esophagus)

    • Lymphatic (if tumor has penetrated the submucosal layer)
    •      This will be in an orderly fashion starting with the
    •       perirectal nodes, internal iliacs, common iliacs,
    •       paraaortic, and scv.

    Hematogenous: Liver, lung, bone, ovaries, & adrenals

    Peritoneal seeding
  99. What does hematogenous mean?
    blood spread
  100. What does peritoneal seeding mean?
    when a tumor breaks through the rectal wall & you have little tumors floating around everywhere in the abdominal wall
  101. What is the anal verge?
    the actual anal opening
  102. What is an Abdominoperineal resection?
    When everything is sewed back together and the person will have a colostomy bag for the rest of their life
  103. What are the treament options for large Intestine Cancer?
    Surgery it the treatment of choice

    • Chemotherapy (5-FU and gemcitabine)
    •       Chemo is used with radiation therapy in pre & post op

    Radiation Therapy
  104. What is the 5 year survival rate for Large Intestine Cancer?
    25%
  105. How is Radiation Therapy use for Large Intestine:
    Can be used pre or post op.

    Fields are designed to encompass the primary tumor volume and pelvic lymph nodes, shrinking to treat primary tumor to a higher dose.

    • A 3-field or 4-field technique is used.
    •     AP, PA, RT adn LT lateral
  106. Large Intestine Field Designs  ( CLASSIC FIELD )

    AP/PA
         Top - L4-L5 interspace
        
         Bottom - Bottom of obturator foramina or 3-5cm       
         below the gross tumor

    Lateral - 2 cm. lateral to pelvic brim & inlet
    • Rt-Lt Laterals
    •      Top & bottom - same as AP/PA
    •  
    •      Anterior - Anterior edge of femoral head

         Posterior - 2 cm behind the bony sacrum
  107. What is proper simulation for a patient with large intestine cancer?
    Supine or Prone

    Prone allows the gluteal fold to decrease

    • Full or empty bladder ( full bladder pushes the small 
    •                                       bowel up out of the way)

    Women have a vaginal marker

    Contrast for bowels

    • Wire scar and anal verge
    •                                  
  108. What is the radiation dose for large intestine cancer?

    External Beam

    Intraoperative Radiation Therapy (IORT)
    Extenal beam:  4500 cGy to large field, 540-1440 cGy boost

    IORT - 1000-2000 cGy of electrons in a single fraction
  109. What are the acute side effects of Large Intestine Cancer
    • Small bowel toxicities ( less than 4500 cGy)
    •    Diarrhea
    •    Abdonimal cramps and bloating
    •    Proctitis
    •    Bloody or mucus discharge
    •    Dysuria

    Leukopenia and thrombocytopenia

    Moist desquamation
  110. What is procitis
    painful rectum ---somewhat like hemmoroids
  111. what is dysuria
    painful urination
  112. what is leukopenia
    decreased white blood cells
  113. what is thrombocytopenia
    decreased platelet counts
  114. what is moist desquamation
    when skin starts to break down and sloft off
  115. what happens with bladder atrophy
    the bladder shrinks
  116. what is enteritis
    Inflammation of the bowel
  117. What are some chronic side effects of Large Intestine Cancer?
    • Persistant diarrhea
    • Increased bowel frequency
    • Procitis
    • Urinary Incontinence
    • Bladder atrophy
    • Enteritis, adhesions and obstructions of the small bowel
  118. Anal cancer occurs more frequently in what gender?
    female
  119. what percentage of large bowel cancers are anal cancers?
    1 -2 %
  120. what is the median age of diagnosis of anal cancer?
    60
  121. There is an increase of anal cancer in men greater than ___ years old.
    This is attributed to male homosexuality and anal intercourse
    45
  122. what are some etiologic factors of anal cancer
    • genital warts
    • genital infections
    • and HPV
  123. In anal anatomy the ______ is where the cells change and it makes the change in histology.
    It goes from adenocarcinoma to squamous cell
    denate line
  124. Clincal presentation of anal cancer is:
    • rectal bleeding
    • pain
    • change in bowel habits
    • sensation of a mass
    • rectal discharge
  125. how do you diagnosis anal cancer
    • physical exam
    • anoscopy and/or proctoscopic exam

    • PET/CT
    • MRI
    • chest x-ray to evulate extent of disease
  126. The pathology of anal cancer ___% are _______and next is basaloid, adenocarcinoma, mucoepidermoid, and melanoma.
    • 80%
    • squamous cell
  127. What is the most common pathology in anal cancer?
    squamous cell
  128. With anal cancer staging is done with teh TNM system and is based on
    the size of the tumor and the depth of invasion
  129. in anal cancer if tumor spread above the dentate line it spreads to what lymph nodes?
    Internal iliac nodes
  130. in anal cancer if the tumor spreads below the dentate line it spreads to what lymph nodes?
    inguinal nodes
  131. A shrinking field is also known as
    a boost dose
  132. what are the treatment techinques for anal cancer
    a combination of radiation therapy and chemotherapy
  133. what is the most common chemotherapy for anal cancer
    5-fu and mitomycin C
  134. what is the treatment field for anal cancer
    • AP/PA or
    • 4 field technique with electrons to the inguinal nodes
  135. Dose RT alone for anal cancer is _________cGy with shirinking fields of _______cGy
    6000-6500 cGy

    4500 cGy
  136. Dose chemorads for anal cancer is ______ cGy with shrinking fields to ______ cGy
    4500

    5940-6940
  137. what is the most painful side effect of anal cancer radistion therapy
    moist desquamation
  138. what are some side effects of anal cancer
    • moist desquamation
    • N&V
    • Diarrhea
    • Bone marrow suppression
  139. usually by the ___ week their skin is slothing off

    (anal cnacer radaition)
    3rd week
  140. Bone marrow suppression leads to _______
    blood counts dropping
  141. the organs at risk when you are treating anal cancer is
    • bladder
    • small bowel
    • femoral heads
  142. bladder can take ____cGy
    small bowel can take ____-cGy
    femoral heads can take _____cGy

    Some doctors will treat patients with a full bladder so it will push the small intestine up & out of the way.
    6000

    4000

    5000
  143. pancreatic cancer has a _____ mortality rate
    high
  144. ____% of all all GI cancers inthe US are pancreatic cancers
    2%
  145. what gender is diagnosised with pancreatic cancer more?
    male
  146. 2/3 of all pancreatic cancer cases occur in the ____ of the pancreas
    head
  147. Pancreatic cancer is rare in people less than ___ years old; and most common in the  ___-___ age group
    40

    50-80
  148. smokers have a __-__  times higher risk of developing pancreatic cancer
    2-3
  149. what are some common causes of pancreatic cancer
    • chronic pancreatitis
    • exposure to benzidine or other industrial chemicals
    • obesity
    • diets high in fats
    • diabetes
  150. Anatomy of pancreas:

    level of ___

    head, body, and ____

    regional nodes: superior & ____ pancreaticoduodenal, portahepatis, suprapancreatic, para-aorta, and splenic hilar nodes
    L1-L2

    tail

    inferior
  151. the portahepatis is where
    the vessels and everything come in & go out of the liver
  152. what are the clinical presentations/symtoms of a patient with pancreatic cancer
    • jaundice
    • abdominal pain
    • anorexia
    • weight loss
    • alceration of bowel
    • bloating
  153. what doees alceration of the bowel mean
    the tumor has grown out of the pancreas & into the bowel
  154. What procedures are used to detect & diagnosis pancreatic cancer
    • history & physical
    • Ct & Pet/Ct
    • ERCP (endoscopic retrograde cholangio-pancreatography
    • ultasound
  155. how is a ERCP done?
    a tube goes down the throat, simular to a colonscopy
  156. What % of pancreatic cancers are adenocarcinoma
    80%

    other pathologys include islet cell tumors, acinar cell carcinomas, and cystadenocarcinomas
  157. what form of staging is done when measuring pancreatic cancer
    TNM
  158. In pancreatic cancer

    T1 - T3 is confined to the pancreas and considered resectable
  159. More than ___% of patients have pancreatic mets at diagnosis
    50%

    surgury is not an option for distant mets; pallative treatment only
  160. what are the routes of spread of pancreatic cancer?
    Direct entension (stomach, duuodenum, and colon)

    • Lymph nodes
    •    superior and inferior pncreatico-duodenal
    •    portahepatis
    •    suprapancreatic
    •    para-aortic
    •    splenic hilar nodes
    •    celiac axis nodes

    • Hematogenous
    •     Liver #1
    •    Lung

    peritoneal seeding
  161. What are treatment options for pancreatic cancer
    • Surgury (Whipple) is the treatment of choice.
    •    Contraindications include: liver mets, extrapancreatic
    •     extension, and adherence to major vessels

    • Chemoradiation
    •    Gemcitabine, 5 Fu, and Cisplatin
    •    External beam dose 4500-5000 cGy
    •    IORT - 1000-2000 cGy in single fraction
  162. What is the 5 year survival rate for pancreatic rate
    less than 10%
  163. What is the proper simulation for pancreatic cancer treatment?
    Supine

    Arms over head with mold

    Contrast for bowel and kkidney enhancement
  164. what is IORT?
    Intra operative radiation therapy

    when is apatient is opened up for surgery they will go ahead and give a blast of radation then close up and start conventional treatments
  165. what are treatment fields for pancreatic treatment
    AP/PA - t10, t11 to l1, width should include duodenal loop and cross midline

    Laterals - 2cm anterior to gross disease and posteriorly 1.5 cm behind anterior vertebral body

    IMRT

    see pg 797
  166. what are the following critcal organ doses

    kidneys
    liver
    small bowel
    spinal cord
    stomach
    • kidneys 1800-2300 cGy
    • liver 2500-3500 cGy
    • small bowel 4500 cGy
    • spinal cord 4500 cGy
    • stomach 5000 cGy
  167. what are some side effects of pancreatic cancer
    • N & V
    • Leukopenia and thrombocytopenia
    • Diarrhea
    • Stomatitis
    • Renal failure
  168. what is aflaxtoxin associated with
    peanut butter
  169. when liver cancer is the primary tumor it is called
    hepatocellular carcinoma (HCC)
  170. hepatobillary tumors are linked to hepatitis B & C, ____ ___, aflatoxin ingestion
    liver cirrhosis
  171. Hepatocellular carcinoma (HCC) is increasing in incidence in the US as results of _______
    hepatitis C
  172. what are some clinical presentations of liver cancers
    • jaundice
    • abdominal pain
    • weight loss
    • fatigue
    • fever
    • night sweats
  173. What is the #1 met. site for liver ca?

     and then ?
    #1 is the lung then the brain
  174. regional lymph nodes of the liver are:
    • portahapatic
    • celiac
    • cystic
    • ppericholeductal
    • hilar nodes
  175. what does the work up include for liver ca?
    • history & physical
    • CBC with chemistry, liver function
    • CA 19-9
    • AFB
    • CEA
    • Ultrasound
    • CT abdomen and pelvis
    • Cholangiography
  176. what is the treatment for liver ca
    • surgery is the mainstay
    • liver transplant for cirrhosis
    • chemotherapy
    • radiation therapy
    •   doses 36-60 Gy
    •    critical structures include bowel, kidneys & cord
  177. Liver cancer is ____ in the US, but more commono in Africa and Asia due to inadequate soil and water
    rare
  178. Liver cancer is more common in what gender
    men
  179. what is the age range that liver ca is diagnosised
    60-70 years old
  180. Liver cancer is closely linked to
    • cirrhosis
    • hepatitis B
    • oral steroids
    • exposure to toxins and vinyl chloride
  181. What are some symtoms of liver cancer
    • weakness
    • loss of appetite
    • bloating and dull pain
    • weight loss
    • cities
    • fever
    • anorexia
    • nausea jaundice
  182. what is the 5 year liver cancer survival rate?
    1%
  183. What is the liver tolerance dose
    30 Gy
  184. What are treatment options of liver cancer
    • surgery
    • chemotherapy (Adriamycin)
    • radiosurgery
  185. Distant mets occurs in ___% of patients at diagnosised
    50%
  186. where does liver cancer spread
    • regional nodes
    • lungs
    • bone
    • brain
  187. what is the hisptogy of liver ca
    • hepatocellular carcinoma
    •    or
    • cholangiocarcinomas (adenocarcinoma)
  188. what is the histology of gallbaldder cancer
    adenocarcinoma
  189. What does the gallbladder do?
    stores & concentrates bile
  190. Gallbladder cancer is more common in what gender?

    It is associated with _________?
    female (4 to 1)

    gallstones
  191. what is the age range of diagnosis of gallbladder ca?
    60-70  years of age
  192. what are some common symtoms of gallbladder ca?
    • n&v
    • fever
    • itching
    • jaundice
    • RUQ pain
    • weight loss
  193. what is the treatment of choice for gallbladder cancer
    surgery

    invasion of the liver is early so partial removal of the liver is often necessary
  194. what is the histology of gallbladder ca?
    adenocarcinoma, squamous cell or sarcoma
  195. what is the 5 year survival rate of gallbladder ca?
    10-30%

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