Pretest - endocrine problems and the breast Flashcards
45yo woman complains to her PCP of nervousness, sweating, tremulousness and weight loos. the thyroid scan shown here with a hot nodule, slightly right of midline, spotty uptake of on radioactive iodineexhibits a pattern that is most consistent with which of the following disorders?
a. hypersecreting adenoma
b. Graves disease
c. lateral aberrant thyroid
d. papillary carcinoma of thyroid
e. medullary carcinoma of thyroid
A. consistent uptake of ioddide
not cancer
both papillary & follicular cancer have good uptake, usually cold- but pts are usually euthyroid
Graves - diffuse uptake
a pt with mild skin pigmentation is admitted emergently to your service b/c of sudden abdominal pain, fever, and a rigid abdomen. her blood work indicates a marked leukocytosis, a blood sugar of 55, Na 119, and K 6.2. her BP is 88/58. she undergoes an exploratory laparotomy. which of the following is the definitive treatment for her primary condition.
a. 10% dextrose infusion
b. bicarbonate
c. hypertonic saline
d. corticosteroids
e. vasopressors
D. for sepsis / hypovolemia
perforation?
“mild skin pigmentation” - jaundice or hemochromatosis; hyperpigmentation from POMC from low cortisol feedback causing overproduction of ACTH (+ melanin)
adrenal crisis
35yo woman with a hx of previous R thyroidectomy for a benign thyroid nodule now undergoes completion thyroidectomy for a suspicious thyroid mass. several hours postoperatively, she develops progressive swelling under the incision, stridor & difficulty breathing. orotracheat intubation is successful. which of the following is the most appropriate next step?
a. fiberoptic laryngoscopy to rule out bilateral vocal cord paralysis
b. administration of IV Ca
c. administration of broad-spectrum abx and debridement of wound
d. wound exploration
e. administration of high-dose steroids & antihistamines
D
–> swelling under incision (wound hematoma)- there wasn’t enough of a hole left in the fascia and hematoma developed
a 62yo woman presents with invasive ductal carcinoma of the eR breast. which of the following findings would still allow her to receive breast conservation surgery (partial mastectomy)?
a. diffuse suspicious microcalcifications throughout the breast
b. multifocal disease
c. previous treatment of a breast Ca with lumpectomy and radiation
d. large tumor relative to breast size
e. persistently postiive margins after multiple reexcisions of the breast ca
B. multifocal disease = multiple tumors within 1 quadrant of the breast. okay to do lumpectomy if lesions are small relative to the size of the breast
DEFINITELY need total mastectomy
- diffuse disease
- large tumor –> b/c might as well take the whole breast
- positive margins
- hx of theraputic radiation
29yo woman presents with a 6mo hx of erythema and edema of the R breast with palpable axillary lympahdenoapthy. a punch biopsy of te skin reveals neoplastic cells in the dermal lymphatics. which of the following is the best next step in her management?
a. a course of nafcillin to treat the overlying cellulitis and then neoadjuvant chemotherapy for breast cancer
b. modified radical mastectomy followed by adjuvant chemotherapy
c. modified radical mastectomy followed by hormonal therapy
d. combined modality chemotherapy & radiation therapy to the R breast with surgery reserved for residual disease
e. combined modality therapy with chemotherapy, surgery and radiation.
E. need to get the lymph nodes as well
likely inflammatory carcinoma, with involvement of lymphatics
50% 5-year survival rate
15yo otherwise healthy female HS student begins to notice galactorrhea. a pregnancy test is negative. which of the following is a frequently associated physical finding?
a. gonadal atrophy
b. bitemporal hemianopsia
c. exophthalmos and lidlag
d. episodic HTN
e. buffalo hump
B
likely proloactinoma
amenorrhea, galactorrhea, lack of libido, impotence, infertility
52yo woman sees her physician with complaints of fatigue, HA, flank pain, hematuria, and abdominal pain. she undergoes a sestamibi scna that demonstrates persistent uptake in the R superior parathyroid gland at 2h. which of the following lab values is most suggestive of her diagnosis?
a. serum acid phosphatase > 120
b. serum alkaline phsophatase > 120
c. serum Ca > 11
d. urinary calcium < 100
e. parathyroid hormone levels < 5
C
recurrent Ca stones –> hyperparathyroidism
53yo woman presents with weight loss and a persistent rash to her lower abdomen and perineum. she is diagnosed with necrolytic migrating erythema and additional workup demonstrates DM, anemia, and a large mass in the tail of the pancreas. which of the following is the most likely diagnosis?
a. Verner-Morrison syndrome (VIPoma)
b. glucagonoma
c. somatostatinoma
d. insulinoma
e. gastrinoma
B
glucagonoma –> necrolytic migrating erythema; DM, anemia, weight loss.
–> high levels of serum glucose; low glucose storage
(reversal insulin)
49yo obese man has become irritable, his face has changed to a round configuration, he has developed purplish lines on his flanks, and he is hypertensive. a 24h urine collection demonstrate elevated cortisol levels. this is confirmed with bedtime cortisol measurements of 700. which of the following findings is most consistent with the diagnosis of Cushing disease?
a. decreased ACTH levels
b. glucocorticoid use for the treatment of inflammatory d/o
c. a 3cm adrenal mass on the CT scan
d. suppression with high-dose dexamethasone suppression testing
e. a 1cm bronchogenic mass on MRI
D
Cushing disease –> anterior pituitary tumor = high ACTH, high cortisol. will respond to suppression b/c it’s in the right spot for negative feedback
Cushing syndrome –> adrenal gland tumor = low ACTH, high cortisol
ectopic tissue –> low ACTH, high cortisol
35yo woman presents with a lump in the L breast. her family hx is negative for breast ca. on exam, the mass is rubbery, mobile, and nontender to palpation. there are no overlying skin changes and the axilla is negative for lymphadenopathy. US demonstrates a simple cm cyst in the area of the palpable mass in the L breast. which of the folllowing represents the most appropriate management of this pt?
a. reassurance and reexamination
b. immediate excisional biopsy
c. . aspiration fo the cyst with cytologic analysis
d. fluoroscopically guided needle localization biopsy
e. mammography & reevaluation of options with new info
A
>35 yo –> don’t wait. get mammogram /MRI
possibly reconsider if already find that it is a simple cyst
<35yo –> mammogram & US –> b/c can detect cyst
55yo woman presets with a slow-growing painlesss mass on the R side of the neck. a FNA shows a well-differentiated papillary carcinoma. a complete neck ultrasound demonstrates a 1cm nodule in the R thyroid without masses in the C/L lobe or lymph node metastasis in the central & lateral neck compartments. with regards to this pt, which of the following is associated w/ a poor prognosis?
a. age
b. sex
c. grade of tumor
d. size of tumor
c. lymph node status
A
older, female (>45yo = poor prognosis) low grade (T0-1, N0, M0), low stage (well-differentiated)
55yo woman presents with a 6cm R thyroid mass and palpable cervical lymphadenopahy. FNA of one of the lymph nodes demonstrates the presence of calcified clumps of sloughed cells. which of the following best management of this thyroid d/o?
a. the pt should be screened for pancreatic endocrine neoplasms and hypercalcemia.
b. the pt should undergo total thyroidectomy with modified radical neck dissection.
c. the pt should undergo total thyroidectomy with frozen section intraoperatively, with modified radical neck dissection reserved for pts with extracapsular invasion
d. the pt should undergo R thyroid lobectomy followed by iodine 131 therapy
e. the pt should undergo R thyroid lobectomy.
B
“calcified clumps of sloughed cells” = psomoma bodies –> papillary carcinoma + spread to lymph nodes
45yo woman is foudn to have suspicious appearing calcifications in the R breast on a screening mammogram. stereotactic biopsy of the calcifications shows lobular carcinoma in situ (LCIS). on exam, both breasts are dense without palpable masses. the neck and b/l axilla are negative for lymphadenopathy. which of the following is the most appropriate management of the pt?
a. frequent self-breast exams and yearly screening mammograms
b. chemotherapy
c. radiation
d. R total mastectomy with sentinel lymph node biopsy
e. b/l modified radical mastectomy
A. LCIS «< DCIS in terms of concern for malignancy
- limited disease = partial mastectomy + radiation + sentinel node
- diffuse disease = total mastectomy + sentinel node
in situ
If DCIS –> D
a 14yo black has her R breast removed /c of a large mass. the tumor weighs 1400g and has a bulging, very firm lobulated surface with a whorl-like pattern. which of the following is the most likely diagnosis?
a. cystosarcoma phyllodes
b. intraductal carcinoma
c. malignant lymphoma
d. fibroadenoma
e. juvenile hypertrophy
D. Fibroadenoma = most common breast tumors between teens to 30s. well-demarcated and firm;
it’s has whorls - something is making that shape (fibrin?)
53yo woman presents with complaints of weakness, anorexia, malaise, constipation, and back pain. while being evaluated, she becomes somewhat lethargic. lab studies include a normal chest xray, serum albumin 3.2, serum Ca 14, serum phosphate 2.6, serum Cl 108, BUn 32, and creatine 2. which of the following is the most appropriate initial management?
a. IV normal saline infusion
b. adminstration of thiazide diuretics
c. administration of IV phosphorus
d. use of mithramycin
e. neck exploration and parathyroidectoy
A –> get rid of serum Ca
Corrected Ca = 14 + 0.8 (0.8) = 14.64
Can be hyperparathyroidism or cancer
1) saline
2) loops (NOT THIAZIDES)
3) bisphosphonate
which of the following pts with primary hyperparathyroidism should undergo parathyroidectomy
a. 62yo symptomatic woman
b. 54 yowoman with fatigue and depression
c. 42yo woman with a history of kidney stones
d. 59yo woman with mildly elevated 24h urinary Ca excretion
e. 60yo woman with mildly decrease dbone mineral density measured at the hip of <2 standard deviations below peak bone density
C
indications for parathyroidectomy
- recurrent stones
- osteoporosis (
45yo woman presents with HTN, development of facial hair, and a 7cm suprarenal mass. which of the following is the most likely diagnosis? a. myelolipoma b. Cushing disease c. adrenocortical carcinoma d pheochromocytoma e. carcinoid
C
virilization / hirsutism –> from sex hormones (testosterone) from adrenal tumor
Cushing disease - from pituitary
36yo woman presents with palpitations, anxiety, and HTN. workup reveals a pheochromocytoma. which of the following is the best approach to optiizing the pt preoperatively?
a. fluid restriction 24h preoperatively to prevent intraoperative congresive heart failure
b. initiation of an alpha blocker 24h before surgery
c. initiation of an alpha blocker 1-3w before surgery
D. initiation of an beta blocker 1-3w before surgery
e. escalating an antihypertensive drug therapy with B blockers - followed by alpha blockage starting at least 1w prior to surgery
C. Always want to give alpha blockers first (or alone, if necessary –> can’t give beta blockers alone d/t alpha vasoconstriction)
intraoperaive - give alpha blockers (b/c of effect of peripheral vasoconstrictors), then beta blockers
33yo pregnant woman notices a persistent, painless lump in the L breast. on exam, the L breast has a single mobile mass without evidence of skin changes or lyphadenopathy in the neck of axilla. an US demonstrates a solid 1cm mass in the upper outer quadrant of the breast. a core-needle biopsy shows invasive ductal carcinoma. the pt is in her first trimester of her pregnancy. which of the following options is in her first treatment of this pt?
a. termination of the pregnancy followed by modified radical mastectomy
b. immediate administration of chemotherapy followed by modified radical mastectomy after delivery of the baby
c. administration of radiation in the third trimester followed by modified radical mastectomy after delivery of the baby
d. total mastectomy with sentinel lyph node biopsy
e. modified radical biopsy
E
–> wait for delivery of the baby before anything else?
any radiation would harm the baby (radiation / chemotherpay or sentinel node)
no evidence that general anaesthesia and nonabdominal surgery increases premature labor or hurts the baby
40yo woman presents with a rash involving the nipple-areola complex for the last month with associated itching. on PE, there is crusting and ulceration of the nipple with surrounding erythema involving the areola and surrounding skin, no palpable breast masses, and no cervical or axillary lymphadenopathy. which fo teh following is the most appropriate next step in the management of this pt?
a reexamine the pt in 1mo
b. corticosteroids cream to the affected
c. administration of oral Abx
d. mammogran and biopsy of the affected area
e. modified radical mastectomy
D
crusting of nipple = Paget
50yo man presents with intractable peptic ulcer disease, severe esophagitis, and abdominal pain. which of the following is most consistent with the diagnosis of Zollinger-Ellison syndrome?
a. hypercalcemia
b. fasting gastrin level of 10
c. fasting gastrin level of 100
d. increase in gastrin level (>200) after administration of secretin
e. decrease in gastrin level (>200) after administration of secretin
D
tumor that produces a lot of gastric acid (paradoxically increases with administration of secretion)
