Breast, endocrine, head and neck Flashcards

Question

Breast cancer staging: T4b and T4c disease

Answer 1

Inflammatory carcinoma is a clinical-pathological entity characterized by diffuse erythema and edema (peau d’orange) involving approximately a third or more of the skin of the breast. The tumor of inflammatory carcinoma is classified cT4d. It is important to remember that inflammatory carcinoma is primarily a clinical diagnosis.

Answer 2

Macrometastasis * \>2mm MIcrometastasis * 0.2-2mm Isolated tumour cell deposits * \<0.2mm

Answer 3

Internal Mammary * Receives suffix b modifier with or without axillary disease Supraclavicular * Receives suffix c modifier with or without axillary disease

Answer 4

Early stage * This includes patients with stage I, IIA, or a subset of stage IIB disease (T2N1). Locally advanced * This includes a subset of patients with stage IIB disease (T3N0) and patients with stage IIIA to IIIC disease.

Answer 5

Usually * low-grade * invasive ductal carcinomas (NST) or; * special types of carcinoma * tubular * cribriform * mucinous Excellent prognosis. Generally have a poor response to traditional chemotherapy but have an excellent response to endocrine therapies

Answer 6

tend to be: * poorly differentiated * Low receptor positivity less likely to respond to endocrine therapy more likely to respond to traditional chemotherapy

Answer 7

T stage N stage M stage Grade HER2status ER status PR status

Answer 8

Patients who are at an increased risk of local and distant recurrence Considerations in this decision include * Age- Young age get better improvement * Likely due to tumour characteristics rather than age per se * Node positive disease * Size (\>2cm) * grade (3) * ER/PR status * HER2 Status * High risk genomics/multigene analysis testing (Prosigna)

Answer 9

HER2 + cancers \>1cm Smaller tumours remain controversial

Answer 10

Fertility preservation * Consider and offer in all premenopausal women Reconstruction/symmetrization Multidisciplinary meeting BRCA status and prophylactic surgery Psychosocial support

Answer 11

Small cells that insidiously infiltrate the mammary stroma and adipose tissue individually and in a single-file pattern. E- Cadherin positive

Answer 12

Malignant cells arranged in cords and nests with varying amounts of gland formation

Answer 13

* Locally advanced * T3 or greater * N2 or N3 * Inflammatory breast cancer * Signs or symptoms suspicious for metastatic disease * Recurrent disease

Answer 14

uncommon fibroepithelial breast tumors * Present as large (\>3 cm), rapidly growing breast mass that is usually palpable * Imaging features of a phyllodes tumor can be suggestive of fibroadenoma * Large size and rapid growth differentiate this capable of a diverse range of biologic behaviors * Least agressive forms behave like benign fibroadenomas, * although with a propensity to recur locally following excision without wide margins. * More aggressive forms can metastasize distantly * degenerate histologically into sarcomatous lesions leaf-like on histology * describes the typical papillary projections that are seen on pathologic examination

Answer 15

Phyllodes tumour Excision biopsy should be performed

Answer 16

Histologically, phyllodes tumors are classified as benign, borderline, or malignant based upon the assessment of four features: * Mitotic activity * Margins- infiltrative or circumscribed * Stromal overgrowth (ie, presence of pure stroma devoid of epithelium) * Degree of cellular atypia

Answer 17

By the Nottingham system (Modified Bloom-Richardson-Elston) * 3 Point system, each scored 1-3 * Tubule formation * Mitotic count * Nuclear pleomorphism * Grade 1 * 3- 5 * Grade 2 * 6-7 * Grade 3 * 8-9

Answer 18

Of the relationship of the superior lanyngeal nerve to the superior pole of the thyroid * I * Nerve crosses the superior thyroid vessels \>1cm above superior thyroid pole * IIa * Nerve crosses the superior thyroid vessels \<1cm above superior thyroid pole * IIb * Nerve crosses at or below the superior thyroid pole

Answer 19

Differentiated * Papillary (85%) * Follicular (12%) Undifferentiated * Anaplastic (\<3%)

Answer 20

Ultrasound * Size * Local invasion * Central and lateral neck nodes Preoperative laryngoscopy CT chest and neck for signs or symptoms of locally advanced disease * Dysphagia * Resp compromise * Haemoptysis * Rapid tumour growth * Voice changes * vocal cord paralysis * tumour fixed to surrounding structures * Exthyroidal extension on USS Consider MRI for operative planning if local invasion suspected

Answer 21

Dysphagia Respiratory compromise Haemoptysis Rapid tumour growth Voice changes Vocal cord paralysis Tumour fixed to surrounding structures Exthyroidal extension on USS

Answer 22

Nerves * RLN injury * SLN injury Endocrine * Hypothyroidism and life long replacement * Parathyroid injury * Transient * Permanent Airway * Bleed, oedema, obstruction Thoracic duct injury * Esp. in large goitres

Answer 23

Tumor \<1 cm without extrathyroidal extension and no lymph nodes – * thyroid lobectomy preferred unless there are clear indications to remove the contralateral lobe Tumor 1 to 4 cm without extrathyroidal extension and no lymph nodes – * Either a total thyroidectomy or thyroid lobectomy * Patient preference * contralateral abnormality * RAI Tumor ≥4 cm, extrathyroidal extension, or metastases – * Total thyroidectomy Radiation exposure * Total thyroidectomy

Answer 24

1.6-2mcg/kg/day

Answer 25

Most commonly induced after parathyroid and thyroid surgery * 1-2% of total thyroidectomy * Transient but severe hypocalcaemia can result from rapid blood product infusion due to citrate load (esp FFP and platelets) Impairs transmembrane depolarisation * Results in parasthesias * muscle spasm * can progress to tetany * Seizures * Cardiac dysfunction * Prolongation of QT interval

Answer 26

Replace magnesium first if concurrent defiency; otherwise replacement will be largely futile Replacement depends on severity: Severe: * Defined as: * symptoms * carpopedal spasm, tetany, seizures * not perioral paraesthesia- this is considered mild * prolonged QT interval * cCa \<1.9mmol/L * IV Calcium gluconate * 1-2g (90-180 elemental calcium) in 50ml of 5% dex infused over 10-20 minutes * then slow infusion ~50mg elemental calcium/hour until adequate oral replacement established Mild * defined as: * 1.9-2mmol/L * symptomatic with mild paraesthesia only * oral replacement * 1500 -2000mg elemental calcium per day in divided doses * elemental comprises 40% of calcium carbonate so 1.25g tab has 500mg * 2.5g Calcium Carbonate BD * vitamin D- cholecalciferol * decreases the dose of calcium required * esp. needed in Vit D deficiency (which most people in NZ have)

Answer 27

American Head and Neck Society (AHNS) classification system for standardised nomenclature * uses radical neck dissection as starting point. Radical neck dissection: * All lymph node levels of the neck, AND * Three non-lymphatic structures * sternocleidomastoid muscle * internal jugular vein * accessory nerve Selective neck dissection: * Any departure from the number of dissected lymph node levels Modified radical neck dissection: * Any departure from the number of non-lymphatic structures sacrificed Extended neck dissection * Any operation extended beyond a radical neck dissection

Answer 28

* behind prevertebral fascia * descends as far as T3 * Important in cervical discitis and abscess

Answer 29

* Extends from base of skull superiorly * continuous through superior and then posterior mediastinum to level of diaphrag inferiorly * Anterior to prevertebral fascia * Posterior to buccopharyngeal fascia * Infection may pass behind the carotid sheath and present in the posterior triangle

Answer 30

lateral continuation of retropharyngeal space bonded laterally to pterygoids and parotid sheath continuous anteriorly with submandibular space

Answer 31

anterior continuation of parapharyngeal space bounded: * Inferiorly by investing cervical fascia anchored to hyoid * Superiorly by floor of mouth * Contains mylohyoid muscle and the submandibular and submental glands

Answer 32

Characteristically aggressive, rapidly spreading "woody" or brawny cellulitis involving the submandibular space. Infection begins in the floor of the mouth Infection is bilateral. Rapidly spreading cellulitis without lymphatic involvement and generally without abscess formation.

Answer 33

Posterior triangle * Posterior aspect of SCM * Anterior aspect of Trapezius * Clavicle Anterior triangle * Midline * Anterior border of SCM * Mandible Anterior triangle can be further divided into: * Submental * Anterior to anterior digastric * Digastric * Between anterior and posterior bellies of digastric * Carotid * Between posterior belly of digastric and superior belly of omohyoid * Muscular * Midline to superior belly of omohyoid

Answer 34

Lancet Oncology 2014 Randomised multicentre trial * T1-T2 primary breast cancers with no palpable lymphadenopathy and who had SLNB positive disease. * Randomised to level I+II LN dissection vs Axillary RTx * Shows: * Non inferiority of RTx alone vs LND in axillary recurrence, overall and disease free survival at 5 years * Underpowered as rate of recurrence lower than expected * Increased lymphoedema in the LND arm

Answer 35

JAMA 2011 Randomised Multicentre Trial * SLNB with completion axillary clearance vs SLNB alone * Included women with T1-T2 primary tumour * Breast conserving surgery with negative margins and clinically node negative disease * Shows that local recurrence rates and survival equivilent between the groups * Main criticism: * Trial protocol mandated no third (axillary) field radiation but most patients received high tangents which included the axilla without a formal axillay field

Answer 36

Radioiodine is administered after thyroidectomy in patients with differentiated thyroid cancer to: * Ablate residual normal thyroid tissue (remnant ablation * Provide adjuvant therapy of subclinical micrometastatic disease * Provide treatment of clinically apparent residual or metastatic thyroid cancer.

Answer 37

Cabergoline Dopamine agonist

Answer 38

Papillary thyroid cancer with all of the following present: * Tumor does not have aggressive histology * cN0 or ≤5 pN1 micrometastases (\<2 mm in largest dimension) * V0 * L0 * M0 * R0 * No I131 uptake outside the thyroid bed on the post-treatment scan, if done 3 additional proposed criteria for low risk disease (not in the original 2009 guidelines) * Intrathyroidal, encapsulated follicular variant of papillary thyroid cancer * Intrathyroidal, well-differentiated follicular thyroid cancer with capsular invasion and no or minimal (\<4 foci) vascular invasion * Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including BRAF V600E mutated

Answer 39

* Tumor * microscopic perithyroidal invasion * aggressive histology * N1 (cervical lymph node metastases) * V1 * R1 * 131I avid metastatic foci in the neck Two additional proposed criteria not included in the ATA guidelines 2009 * Clinical N1 or \>5 pathologic N1 with all involved lymph nodes \<3 cm in largest dimension * Multifocal papillary thyroid microcarcinoma with extrathyroidal extension and BRAF V600E mutated (if known)

Answer 40

Any of the following present: * Macroscopic tumour invasion * M1 * R2 * Postoperative serum thyroglobulin suggestive of distant metastases Two proposed additional features not included in the original ATA guidelines 2009 * Pathologic N1 with any metastatic lymph node ≥3 cm in largest dimension\* * Follicular thyroid cancer with extensive vascular invasion (\>4 foci of vascular invasion)

Answer 41

* Columnar * Tall * Insular * Hobnail * Hürthle * Follicular thyroid cancer

Answer 42

Low risk disease * generally does not benefit form RIA Intermediate risk disease * There is limited evidence of significant benefit * Large retrospective analyses have shown some survival benefit * no good RCT's * RAI generally offered. * Good indications include * R1 * cN(+) * Combinations of * Aggressive subtypes * age * Multifocality * V1 * pN \>5 nodes but \<3cm High risk * Should receive RAI

Answer 43

follicular thyroid * Endodermal origin * Thyroid arises as a tissue bud at the base of the the tongue at the foramen caecum. * descends into the neck and forms bilobed (left and right) glandular tissue * Distal aspect of the thyroglossal duct may form pyrimidal lobe (off midline) or if patent may form a thyroglossal cyst C- Cells (calcitonin producing) * Neural crest derived * Fourth pharyngeal pouch * reside in the lateral posterior upper 2/3 of the developed thyroid

Answer 44

Failure of descent of some, or all, of the thyroid down the thyroglossal tract into the neck Thyroid tissue at base of tongue Some malignant potential but low (~30 case reports) * TSH suppression may reduce the size and remove need for surgical resection Most will represent complete non descent of the thyroid * always assess the full tract * USS neck * Tc99 * consider reimplantation of follicular tissue into SCM

Answer 45

Hereditary breast and ovarian cancer genes BRCA genes encode structurally unrelated tumour suppressor proteins involved in DNA repair and apoptosis * Mutation leads to loss of function 2 genes, 1 and 2 * Both normally expressed in breast and ovarian tissue Both autosomal dominant with high penetrance Especially early onset of breast cancer * increased incidence of tumors of other organs * Ovarian (low risk \<40) * fallopian tubes * prostate * pancreas

Answer 46

Breast * 70% Ovarian * 40%

Answer 47

Breast * 70% Ovarian * 15%

Answer 48

BRCA1 BRCA2 Li-Fraumeni * TP53 Peutz-Jeghers * STK11 Cowden (PTEN hamartoma syndrome) * PTEN Heriditary diffusse gastric cancer syndrome * CDH1 Lynch syndrome * MSH1, MLH1, MSH2, PMS2, EPCAM PALB2

Answer 49

Extended genetic testing panel for women with high familail risk for breast cancer * Increases the sensitivity of testing to a level at which a negative result suggests a decreased risk of breast cancer (i.e drop to group 2) * 8 genes included * ATM * BRCA1 * BRCA2 * CDH1 * CHEK2 * PALB2 * PTEN * TP53

Answer 50

Gynaecomastia * Benign enlargement of male breast tissue, resulting from a proliferation of the glandular component of the breast. Firm subareolar gland and ductal tissue will be palpable on examination, Pseudogynaecomastia * Breast enlargement caused by excess adipose tissue

Answer 51

Common * Incidence of more than 30%. Results from relative oestrogen excess or relative testosterone deficiency resulting in a high oestrogen-to-testosterone ratio. Can occur at any age and may be physiological or pathological * Physiological occurs in newbons, puberty, aging and obesity * Pathological is from environmental exposures, illnesses, and some genetic conditions

Answer 52

Newborn period During puberty Ageing * Gynaecomastia is more common in men aged over 50, owing to the general decline in testosterone levels and a tendency towards weight gain in later life. Obesity * In overweight men, breast tissue is stimulated by excess oestrogen resulting from the conversion of testosterone to oestradiol by the enzyme aromatase found in adipose tissue.

Answer 53

Gynaecomastia is usually bilateral * 10% of cases can involve just one breast * always consider the possibility of breast cancer in a unilateral presentation.

Answer 54

Antiandrogens * finasteride * bicalutamide Antihypertensives * spironolactone Antiretrovirals Hormones * oestrogen * prednisone H2 receptors blockers Antipsychotics many others

Answer 55

The Nottingham hospital gynaecomastia pathway provides these guidelines for idiopathic gyanecomastia * Sexual maturation has been reached. * In cases of idiopathic gynaecomastia in men under the age of 25 then a period of at least 2 years has been allowed for natural resolution * Screening has been undertaken, prior to referral, for endocrinological and drug related causes. * Non-surgical treatments have been tried and have been unsuccessful * BMI as measured by the NHS is between 18 and 25 and has been within this range for year as measured and recorded by the NHS * Confirmed non-smoker * Photographic evidence

Answer 56

In patients with physiological gynaecomastia, especially adolescent boys, reassurance can be given that most cases are transitory, with more than 90% resolving within three years.

Answer 57

Conservative * most will be transient and resolve spontaneously especially in adolescent males Medical * Tamoxifen is effective but not licenced for this * Medical management is associated with a high success rate and avoids surgical intervention, but once fibrosis occurs it is largely ineffective. * Tamoxifen 20mg od for 3 months is recommended. * Treatment should be stopped after 3 months whether a response is seen or not. Surgery

Answer 58

Appropriate baseline blood tests include: * Liver function * Thyroid function * Renal function. If normal hormone blood screen * Testosterone * LH * Luteinising hormone * FSH * Follicle stimulating hormone * Oestradiol * SHBG * Sex hormone binding globulin * allow estimation of free testosterone * PRL * prolactin.

Answer 59

* Dehydroepiandrosterona (DHEA) * Precursor to testosterone and dihydrotestosterone * Dehydroepiandrosterone Sulfate (DHEA-S) * (only produced in adrenal (and brain) * Useful to rule out gonad origin of sex steroid excess * Testosterone

Answer 60

Benign, non proliferative * Distension of the terminal duct lobular unit * Results from obstruction of the efferent ductule 50-90% of women * most common age 35-50 Often assymptomatic, may cause pain or lump Can be aspirated for symptomatic management

Answer 61

BIRADS 4-5 * Thick or complex septation * Presence of a solid component * Absence of posterior wall enhancement

Answer 62

BIRADS 2-3 Homogenous low-level internal echoes due to echogenic debris * without: * solid components * thick walls * thick septa * vascular flow

Answer 63

Breast Imaging-Reporting and Data System is a risk assessment and quality assurance tool developed by American College of Radiology that provides a widely accepted lexicon and reporting schema for imaging of the breast. It applies to mammography, ultrasound, and MRI Scores are graded 0-6 (inclusive) with an increasing risk of malignancy by increasing BIRADS category

Answer 64

Assessment * Incomplete Management * Recall and or review prior imaging Malignancy rate * N/A

Answer 65

Assessment * Negative Management * Routine screening/surveillance Malignancy rate * Essentially 0%

Answer 66

Assessment * Benign Management * Routine screening/surveillance Malignancy rate * Essentially 0%

Answer 67

Assessment * Prrobably benign Management * Short interval surveillance (6 months) Malignancy rate * \>0 but \<2%

Answer 68

Assessment * Suspicious * 4a low suspicion * 4b moderate suspicion * 4c high suspicion Management * Tissue diagnosis Malignancy rate * 4a 2-10% * 4b 10-50% * 4c 50-95%

Answer 69

Assessment * Highly suggestive of malignancy Management * Tissue diagnosis Malignancy rate * \>95%

Answer 70

Assessment * Known biopsy proven malignancy Management * NA Malignancy rate * NA

Answer 71

Benign non proliferative breast lesion. Papillary apocrine change is a proliferation of ductal epithelial cells showing apocrine features, characterized by eosinophilic cytoplasm

Answer 72

Benign non proliferative lesion Mild hyperplasia of the usual type is an increase in the number of epithelial cells within a duct that is more than two, but not more than four, cells in depth. The epithelial cells do not cross the lumen of the involved space.

Answer 73

Benign proliferative breast lesion without atypia Usually found as an incidental finding on biopsy of mammographic abnormalities or breast masses, characterized by an increased number of cells within the ductal space. Although the cells vary in size and shape, they retain the cytological features of benign cells. No additional treatment is needed for ductal hyperplasia. The risk of subsequent breast cancer in women with usual ductal hyperplasia is small, and chemoprevention is not indicated.

Answer 74

Intraductal papillomas consist of a monotonous array of papillary cells that grow from the wall of a cyst into its lumen. Although they are not concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in situ (DCIS). * 16% upgraded to malignancy on excision in a metanalysis * Newer data suggest in the absence of atypia on biopsy the rate of malignancy is very low and excision may not be necessary.

Answer 75

Sclerosing adenosis is a lobular lesion with increased fibrous tissue and interspersed glandular cells. May present as a mass or a suspicious finding on mammogram. No treatment is needed The risk of subsequent breast cancer in this population is small, and chemoprevention is not indicated

Answer 76

AKA complex sclerosing lesions Usually incidental when a mass or radiologic abnormality is removed or biopsied. * Occasionally large enough to be detected by mammography, which cannot reliably differentiate between these lesions and spiculated carcinoma. Characterized microscopically by a fibroelastic core with radiating ducts and lobules. Most series show that 8 to 17 percent of surgical specimens at subsequent excision are positive for malignancy * there is some evidence that radial scars may be premalignant lesions that can slowly progress from scar to hyperplasia to carcinoma. No additional treatment beyond excision is needed for radial scars. The risk of subsequent cancer after excision is small, and chemoprevention is not indicated.

Answer 77

Most common benign tumor of breast * most common between the ages of 15 and 35 years * In 20% of cases, multiple fibroadenomas occur in the same breast or bilaterally. The etiology of fibroadenomas is not known * hormonal relationship is likely since they persist during the reproductive years, can increase in size during pregnancy or with estrogen therapy, and usually regress after menopause.

Answer 78

Benign solid tumors containing glandular as well as fibrous tissue The risk of subsequent breast cancer is slightly elevated only if the fibroadenoma is complex, if there is adjacent proliferative disease, or if there is a family history of breast cancer. For the majority of women with simple fibroadenomas, there is no increased risk of developing breast cancer If a presumed fibroadenoma increases in size or is symptomatic, then excision is mandated to rule out malignant change and confirm the diagnosis * Rapid growth of a lesion raises the suspicion for a phyllodes tumor, * the true incidence of phyllodes tumor at time of excision is rare (0.8 to 9 percent) * CNB cannot definitively distinguish phyllodes tumours from fibroadenoma

Answer 79

Benign proliferative breast lesion with atypia Includes both of: * Atypical Ductal Hyperplasia (ADH) * Atypical Lobular Hyperplasia (ALH) Both confer a substantial increase in the risk of subsequent breast cancer (RR 3.7 to 5.3) * both ipsilateral and contralateral * provides evidence of underlying breast abnormalities that predispose to breast cancer * Cumulative incidence of breast cancer over 30 years approaches 35%

Answer 80

Yearly mammography and twice-yearly breast exams is appropriate Avoid risk increasing factors * Stop OCP * Avoid HRT * lifestyle and dietary changes Primary prevention with the selective estrogen receptor modulators tamoxifen or raloxifene, or an aromatase inhibitor, may be considered in women with AH * benefits and risks must be discussed thoroughly. The Gail model incorporates atypical proliferative disease into a risk calculation that can be used to identify women who are appropriate candidates for primary prevention of breast cancer

Answer 81

The Gail model * parameters are: * age * first menstrual period * first degree relatives with breast cancer * previous breast biopsy * ALH present * race lifetime risk of breast cancer \>1.7% should be referred to a breast surgeon for consideration of risk reduction medications and other strategies

Answer 82

Benign proliferative lesion with atypia AKA columnar cell change with atypia or columnar cell hyperplasia with atypia. Typically diagnosed on biopsies done for calcifications found on screening mammograms. The available data suggest that the risk of local recurrence or progression to invasive cancer is low

Answer 83

Benign, usually solitary Composed of mature fat cells. Soft, nontender, well-circumscribed masses. * sometimes difficult to distinguish lipomas from other conditions; the diagnosis can be confirmed with a core or excisional biopsy. * Core biopsies are somewhat problematic for lipomas, as it is difficult to be certain that the diagnosis is concordant, and lipomas should be surgically excised if they cause diagnostic confusion, continue to enlarge, or grow rapidly There is no increased risk of subsequent breast cancer

Answer 84

Benign condition that most commonly occurs as the result of breast trauma or surgical intervention. Fat necrosis can be confused with a malignancy on physical examination and may mimic malignancy on radiologic studies. * It is sometimes necessary to biopsy these lesions to confirm the diagnosis No increased risk of malignancy

Answer 85

Histologically typical fibroadenoma \>10cm excision is recommended to ensure that a phyllodes tumour is not the diagnosis Phyllodes tumours have a more cellular stromal component than fibroadenomas

Answer 86

Typical fibroadenomas most common in the upper outer quadrant ages 10-18 may grow or regress with time Excision over 5cm is reasonable

Answer 87

AKA lymphocytic mastitis or lymphocytic mastopathy Typically premenopausal women who have longstanding T1DM. Suspicious breast mass with a dense mammographic pattern. * Core biopsy is recommended for diagnostic confirmation. Pathology shows dense keloid-like fibrosis and periductal, lobular, or perivascular lymphocytic infiltration Pathogenesis unknown, possibly autoimmune * histologic features are similar to those seen in other autoimmune diseases Excision is not necessary * no increased risk of subsequent breast cancer.

Answer 88

BI-RADS classification provides a scale that identifies breast tissue density as being in one of four categories * A – almost entirely fatty * B – scattered areas of fibroglandular density * C – heterogeneously dense (may obscure small masses) * D – extremely dense (lowers the sensitivity of mammography) * "radiologically dense breasts" refers to categories C and D Breast density is important in two ways 1. breast density affects imaging reliability 2. dense breasts are an independant risk factor for breast cancer

Answer 89

AKA fibroadenolipoma, lipofibroadenoma, or adenolipoma Benign varying amounts of glandular, adipose, and fibrous tissue Present as discrete, encapsulated, painless masses or are found incidentally on screening mammography. Diagnosis can be difficult with limited tissue * do not have specific diagnostic features. * Core biopsy insufficient to establish the diagnosis. Coexisting malignancy can occur, excision is recommended

Answer 90

Pure epithelial neoplasms of the breast. * They are distinguished from fibroadenomas by sparse stromal elements. Divided into two main groups: tubular and lactating adenomas. * Lactating adenomas occur commonly in pregnancy. * well circumscribed and lobulated. May require excision because of their size but do not have malignant potential

Answer 91

benign inflammatory condition of the breast * presents as periarealar mastititis almost exclusively seen in smokers * Ducts become obstructed and infected * Most likely a consequence of tissue hypoxia and injury from nicotine and its derivatives * Ductal plugging with keratin is seen * there is some postulation that ductal hyperplasia may contribute

Answer 92

Pseudoangiomatous Stromal Hyperplasia Benign stromal proliferation that simulates a vascular lesion * may present as a mass or thickening on physical examination. * most common appearance on mammography and ultrasound is a solid, well-defined, noncalcified mass. Histologic appearance is a pattern of slit-like spaces in the stroma between glandular units * May be confused with mammary angiosarcoma If any suspicious features on imaging, the diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis, and excisional biopsy should be performed. * if no suspicious imaging characteristics, a diagnosis of PASH at core biopsy is considered sufficient, and surgical excision is not always necessary There is no increased risk of subsequent breast cancer associated with PASH.

Answer 93

Rare benign well circumscribed breast lesion Malignant potential is low but excision usually recommended esp over 1.6cm

Answer 94

composition: * cystic or completely cystic \*: 0 points * spongiform \*: 0 points * mixed cystic and solid: 1 point * solid or almost completely solid: 2 points echogenicity: * anechoic: 0 points * hyper- or isoechoic: 1 point * hypoechoic: 2 points * very hypoechoic: 3 points shape: * wider than tall: 0 points * taller than wide: 3 points margin: * smooth: 0 points * ill-defined: 0 points * lobulated/irregular: 2 points * extra-thyroidal extension: 3 points Any and all findings in the final category are also added to the other four scores. * echogenic foci: (choose one or more) * none: 0 points * large comet-tail artifact: 0 points * macrocalcifications: 1 point * peripheral/rim calcifications: 2 points * punctate echogenic foci: 3 points

Answer 95

TR1: 0 points * benign TR2: 2 points * not suspicious TR3: 3 points * mildly suspicious TR4: 4-6 points * moderately suspicious TR5: ≥7 points * highly suspicious

Answer 96

TR1: * no FNA required TR2: * no FNA required TR3: * ≥1.5 cm follow up * ≥2.5 cm FNA * follow up: * 1, 3 and 5 years TR4: * ≥1.0 cm follow up, * ≥1.5 cm FNA * follow up: * 1, 2, 3 and 5 years TR5: * ≥0.5 cm follow up, * ≥1.0 cm FNA * annual follow up for up to 5 years

Answer 97

The Bethesda system standardised reporting system for cytopathology of the thyroid gland Graded 1-6 Provides guidance on risk of malignancy and subsequent management

Answer 98

Category * Non diagnostic Risk * 1-4% Management * Repeat FNA with USS guidance

Answer 99

Category * Benign Risk * 0-3% Management * Clinical follow up

Answer 100

Category * Atypia of undetermined significance or * Follicular lesion of undetermined significance Risk * 5-15% Management * Repeat FNA

Answer 101

Category * Follicular Neoplasm or * Suspicious for a follicular neoplasm Risk * 15-30% Management * Diagnostic surgical lobectomy

Answer 102

Category * Suspicious for malignancy Risk * 60-75% Management * Near total thyroidectomy or surgical lobectomy

Answer 103

Category * Malignant Risk * 97-99% Management * Near total thyroidectomy

Answer 104

Most parathyroid glands are ultimately found in a eutopic position. The upper parathyroid glands * located in a more constant position than the lower glands * typically found at the level of cricoid cartilage * posterior to the thyroid gland, in close proximity (1 to 2 cm) to where the RLN crosses the inferior thyroid artery. The lower parathyroid glands * often located posterior and inferior to the lower pole of the thyroid gland. * These glands lie anterior to the RLN. If the parathyroid glands cannot be found in these eutopic positions, ectopic locations should be explored

Answer 105

Ectopic superior parathyroid gland exploration should include the tracheoesophageal groove and posterior mediastinum. Often found in a retroesophageal or parapharyngeal location. Lower parathyroid glands are found in an ectopic location more frequently than upper parathyroid glands largely because of their longer, more variable embryologic descent. Sites of ectopic lower parathyroid glands include: * thyrothymic ligament * thymus or perithymic fat * carotid sheath * anterior mediastinum. * Occasionally, an abnormal parathyroid gland may be intrathyroidal. * In such cases, the gland is typically located in a superficial or subcapsular location and can be easily extracted from surrounding thyroid tissue. * an ipsilateral partial or complete thyroid lobectomy is required in some cases.

Answer 106

BIA ALCL Breast implant associated anaplastic large cell lymphoma

Answer 107

Breast Implant Associated Anaplastic Large Cell Lymphoma * Rare- likely 1 in 1000-10000 women with textured implants * vastly less common in non textured implants * Peripheral CD-30 T cell derived lymphoma * Relatively indolent course * Early stage disease has an excellent prognosis * Usual presentation is with a seroma * ~10 years after placement * often diagnosed at revision surgery for the same * less common presentation is a solid mass * Likely aetiology is low grade chronic inflammation associated with implant prostheses * Surgical resection of the implant, capsule and any associated mass is probably all that is needed for therapy in early stage disease * Recurrent or advanced disease (which is rare) should be managed with chemotherapy

Answer 108

alcohol male smoking HPV

Answer 109

Each cavity space has a seperate staging system Best defined by local vs locally agressive or distant disease * Local- * stage I-II * no nodes * Locally aggressive or distant mets * Stage III and IV * 4cm or T4 is a good general rule Management * local * single modality * RTx, excision etc * Aggressive and distant * Multimodality * modified radical dissection * RTx * chemo

Answer 110

the smaller the gland the more likely to be malignant

Answer 111

Most common * Pleomorphic adenoma Others * Myoepithelioma * Basal cell adenoma * Warthin tumor * Oncocytoma * Lymphadenoma * Cystadenoma * Sialadenoma * Ductal papillomas * Sebaceous adenoma * Canalicular adenoma and other ductal adenomas

Answer 112

Most common * mucoepidermoid carcinoma Others * Adenoid cystic carcinoma * Acinic cell carcinoma * Polymorphous adenocarcinoma * Clear cell carcinoma * Basal cell carcinoma * Intraductal carcinoma * Adenocarcinoma, NOS * Salivary duct carcinoma * Myoepithelial carcinoma * Epithelial-myoepithelial carcinoma * Carcinoma ex pleomorphic adenoma * Secretory carcinoma * Sebaceous adenocarcinoma * Carcinosarcoma * Poorly differentiated carcinoma * Undifferentiated carcinoma * Large cell neuroendocrine carcinoma * Small cell neuroendocrine carcinoma * Lymphoepithelial carcinoma * Squamous cell carcinoma * Oncocytic carcinoma

Answer 113

The F's * Formication * Fistula * Freys syndrome * Facial nerve injury * Flap necrosis * First bite syndrome

Answer 114

* Superficial parotidectomy and selective anterior neck dissection is indicated in melanoma arising anterior to the line between the tragi * Selective posterior neck dissection without parotid surgery for lesions posterior to the tragi

Answer 115

Torus palatinus. Painless, benign boney protuberance no surgery required

Answer 116

lower lip due to sun exposure

Answer 117

Elderly, dehydrated staph aureus rehydration antibiotics

Answer 118

Tracheoarterial fistula! * Put a finger in or overinflate the cuff to compress against the sternum * Take to theatre * resection of the innominate artery

Answer 119

**It's normal position** thymus is the most common site of an ectopic gland

Answer 120

Posterior midline oesophageal **false** diverticulum Occurs through Killians triangle * bordered by: * inferior fibres of inferior constrictor (oblique) * upper fibres of crichopharyngeus

Answer 121

angiosarcoma

Answer 122

Prognosis is very poor, lesions tend to metastasize early to lung and bone Treatment is with excision where possible Taxane based chemotherapy may be used as neoadjuvant, adjuvant or palliative treatment

Answer 123

Improved local control Small survival advantage

Answer 124

Locally * involved margins To the axilla * any nodes * T3 tumour * high risk disease which comes close to meeting the threshold for radiotherapy

Answer 125

The modified van Nuys prognostic index * variables are * age * size * margin * pathological classification MSKCC have an online nomogram with more variables * it may be superior to van Nuys but the jury is out

Answer 126

START trial * classic is 50Gy in 25 fractions * higher dose per fraction fewer fractions is now more standard * Dunedin uses 40.5Gy in 15 fractions

Answer 127

radiotherapy increases the baseline risk of any procedure by 1/3

Answer 128

Field includes level II nodes

Answer 129

within 3 months ideally 8-12 weeks post operatively

Answer 130

An autoimmune hyperthyroidism causes by antibidies to the TSH receptor which simulate the effects of TSH Assays are available and can be used in patients in whom the underlying aetiology is not clear as the most recent assays have very high sensitivity and specificity (TRAb assay)

Answer 131

TSH suppression can be achieved by administration of thyroxine the aim is to achieve low normal TSH levels in patients with an increased risk of recurrence There does not appear to be a long term benefit beyond 5 years

Answer 132

OBS techniques are classified into “level I” and “level II” procedures. * Level I is performed when less than 20% of breast volume is to be excised. * tissue displacement techniques are performed to repair the defect, and the nipple-areola complex (NAC) is repositioned if required. * Level II techniques are used where resection of 20%–50% of the breast volume is required. * Many techniques exist * involves extensive skin resection with a variety of volume displacement or replacement methods. * local tissue displacement and glandular reshaping methods are used to fill defects * eg, round-block, omega, vertical, radial, V-, J-, and L-type incisions

Answer 133

0.4mSv or ~7 weeks of background radiation

Answer 134

Surgery * 1cm margin excision * positive margins are associated with an unacceptable high recurrence rate * most markedly in borderline and malignant phyllodes tumours * axillary surgery is not needed Adjuvant radiotherapy * not indicated for benign * indicated for borderline and malignant Chemo * no established role * maybe for very high risk cancers Hormone * no

Answer 135

The majority of patients with benign and borderline phyllodes tumors are cured by surgery. The survival rate for malignant phyllodes tumors is approximately 60 to 80 percent at five years

Answer 136

Chemodectomas Paragangliomas

Answer 137

Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia, small organs consisting mainly of neuroendocrine cells that are derived from the embryonic neural crest and have the ability to secrete catecholamines

Answer 138

All carotid body tumours should be surgically removed Although they typically have an indolent course they will eventually progress and may develop vascular or neural invasion which complicates their management They are easier to remove when small

Answer 139

Vascularity * these are highly vascular lesions * they often encase the external carotid artery * rarely the internal * vascularity is through a rich network in the adventitial plane around the lesion Nerves * Involvement of the cervical and cranial nerves * vagus * note paragangliomas may also arise here and mimic carotid body tumours * glomus intravagale * recurrent and external laryngeal

Answer 140

The axillary vein is identified having incised the clavipectoral fascia along the lateral border of pectoralis major and then by following the latissimus cranially until its tendon is identified. * At the point where the latissimus turns tendinous it is crossed by the axillary vein. * The dissection is done sharply, and accomplishes both the identification of the axillary vein and mobilization of the lateral border of the specimen. * The only important structure that is encountered during this approach is the intercostobrachial nerve, which is usually found one-half to two-thirds of the way to the vein * The fat covering is then divided along the anterior aspect of the vein from lateral to medial * no major neurovascular structures are encountered across the anterior aspect

Answer 141

The thoracodorsal vein is usually the first branch of the axillary vein encountered when dissecting from lateral to medial along the inferior border beginning at the lateral border of latissimus dorsi * the nerve arises deep to the axillary vein and runs medial to the vein * identification of the vein is the key manoeuvre

Answer 142

1400 women of screen age are offered screening * 1000 turn up * 70 are recalled * 30 undergo biopsy * 24 are benign diagnoses * 6 are cancer * 2 length time bias * 2 lead time bias * 2 have improved survival * 40 are normal

Answer 143

BreastScreen Aotearoa provides a breast screening service for women aged 45 to 69. Eligible women can have a free mammogram every 2 years to check for breast cancer.

Answer 144

2mm this is based on a large meta-analysis (Ann. Surg. Oncol. 2016) 0f nearly 8000 patients in some studies 2mm margin effect was removed with radiotherapy There was no additional protective effect with wider margins

Answer 145

Plasma cell mastitis * classically involves more than one breast segment

Answer 146

Prolactin * Pituitary adenoma PTH * Parathyroid adenoma Gastrin * Gastinoma Insulin, C peptide and glucose levels * insulinoma

Answer 147

Mineralocorticoid hormone Synthesized in adrenal cortex (glomerulosa) from cholesterol Increases reabsorption of salt (and hence water) by Na+/K+ and Na+/H+ antiporters. * net effect is loss of potassium and hydrogen and retention of na+ and water. Release is mediated by angiotensin II

Answer 148

C- Cafe au lait A- Axillary and inguinal freckling F- Fibromas E- Eye signs S- Skeletal- sphenoid winging and long bone dysplasia P- Phaeochromocytoma O- Optic gliomas T- Tumours- sarcomas, nerve sheath tumours

Answer 149

moon face plethora striae central obesity buffalo hump hirsutism loss of libido menstrual irregularity depression or psychosis proximal myopathy easy bruising

Answer 150

Often asymptomatic Stones * nephrolithiasis * also polyuria, thirst * renal failure Bones * pathological fractures from osteoporosis * z score Moans * abdominal pain from * pancreatitis * PUD * nausea and vomiting Groans * constipation Psychiatric undertones * depression * headaches * confusion

Answer 151

Tachycardia and AF Sweating Facial and palmar flushing Weight loss Hair loss Hyperreflexia Eye signs * diplopia * exopthalmos * lid lag * lid retraction

Answer 152

Cold intolerance Weight gain Hyporeflexia Coarse hair Bradycardia/Hypotension Hypothyroid facies * periorbital oedema * loss of the lateral 1/3 of the eyebrows * peaches and cream complexion

Answer 153

Grade 0 * no visible or palpable goitre Grade 1 * palpable but not visible in the normally positioned neck Grade 2 * visible in the normally positioned neck

Answer 154

Comedo Cribriform Micropapillary Papillary Solid

Answer 155

2mm * wider margins do not convey an additional benefit * narrower margins are associated with a 2x increase in recurrence rates

Answer 156

Overall 10-20% * in patients presenting with symptomatic DCIS this is closer to 50%

Answer 157

Definate: * Mastectomy as the lymphatic drainage will be permanently altered and therefore post operative SLNB will not be possible if maligancy is subsequently recognised in the specimen * This population is generally at a higher risk of cancer due to larger DCIS area Relative * Symptomatic disease (50%) rate of malignancy in the specimen * DCIS \>5cm * Imaging consistent with malignancy but DCIS on biopsy only

Answer 158

By necrosis, subtype and nuclear features. * Low grade * evenly spaced cells * small, centrally placed nuclei * few mitoses * High grade * pleomorphic irregularly spaced cells * enlarged nuclei * frequent mitoses * Intermediate grade * features between those above

Answer 159

1cm deep(medial) and inferior to the tragal pointer The posterior belly of digastric runs in the same plane as the nerve * the stylomastoid foramen is above the upper margin of that muscle Tympanomastoid suture line * this is the most precise marker for the facial nerve Retrograde dissesction Drill out the mastoid and identify the nerve from within the mastoid bone

Answer 160

BRCA 1 and 2 pathogenic variant screening: * individuals with a combined BRCA1 and BRCA2 pathogenic variant probability of ≥10% using a validated pathogenic variant prediction tool * e.g. CanRisk or Manchester score. * this may include unaffected individuals and obligate carriers with ≥10% pathogenic variant probability * individuals affected with breast cancer: * with triple negative pathology diagnosed ≤50 years * with triple negative breast cancer diagnosed at any age where there is a close relative with breast or ovarian cancer * diagnosed ≤40 years * individuals with high grade ovarian cancer diagnosed at any age * males affected with prostate cancer who meet prostate cancer panel testing criteria Pathogenic variant specific BRCA1 or BRCA2 testing: * a pathogenic somatic variant detected on tumour testing for this individual * a personal and/or family history of breast, ovarian, prostate or pancreatic cancer from a population where a common founder pathogenic variant exists (Ashkenazi jews) * a familial BRCA1 or BRCA2 pathogenic variant has been identified

Answer 161

50% of people have nodules on USS and autopsy, most are benign. * benign nodules include: * colloid nodules * follicular adenomas * hurthle cell adenomas * pseudonodules of thyroiditis

Answer 162

T1 * a * 0-1cm * b * 1-2cm T2 * 2-4cm T3 * \>4cm * invasion into straps only T4 * resectable soft tissues * non-resectable structures * great vessels * prevertebral fascia

Answer 163

Can almost always be managed with hemithyroidectomy unless there are high risk features * Patient * radiation * family history * Tumour * invasion * nodes * mets

Answer 164

Papillary cancer- T1b and T2 disease * patients have equivalent survival with total thyroidectomy and with hemithyroidectomy * decision for total thyoridectomy should be made if there are high risk factors * Tumour related * contralateral thyroid nodules/multifocality * nodal disease * high risk subtypes * Patient related * radiation * family history of thyroid cancer * patient choice

Answer 165

This is T3-4 disease and is managed with total thyroidectomy * other high risk features in addition to size include: * tumour factors * aggressive histologies * extrathyroidal extension * multifocal disease * vascular invasion * nodal and distant metastatic disease * patient factors * family history of thyroid cancer * radiation exposure

Answer 166

Clinical or radiologically apparent lateral nodal disease should undergo FNA to confirm the disease. * selective nodal dissection of levels II,III,IV and VB is warranted

Answer 167

Prophylactic considered in * high risk tumours * associated lateral neck node involvement * T3/4 disease Therapeutic * for clinically, radiologically or intraoperatively identified abnormal nodes

Answer 168

Thyroid * total thyroidectomy Nodes * prophylactic bilateral level VI dissection warranted * therapeutic selective lateral dissection in FNA proven disease * the role for prophylactic lateral dissection is debated in patients with high calcitonin levels (\>500) * it is neither recommended for, nor against in the ATA guidelines

Answer 169

Anaplastic thyroid cancer is seldom mangaged by surgery as it is so aggressive it is seldom resectable at presentation there is occasionally a role for palliative thyroidectomy for local control if there is resectible disease AND it will not delay chemoradiotherapy

Answer 170

Use antithyroid medication * PTU in the first trimester * Carbimazole from the second trimester onward RAI is contraindicated Surgery is rarely necessary

Answer 171

RLN injury * 5% transient * 1% permanent Hypoparathyroidism * 10-20% transient * 1-2% permanent Post operative bleeding * \<1%

Answer 172

These include blood and urinary testing * Bloods * PTH * Calcium * total * ionised * Albumin * Vitamin D * Creatinine * Phosphate * ALP * Urine- 24 hour collection for: * volume * calcium * creatinine * a calcium: creatine of \<0.01 is suggestive of Familial Hypercalciuric Hypercalcaemia

Answer 173

Familial Hypercalciuric hypercalcaemia is a rare condition * it is only able to be differentiated from hyperparathyroidism by a low urinary calcium * a calcium:creatinine of \<0.01 is indicative * hyperparathyroidism is characterised by a normal or high urinary calcium

Answer 174

Multigene analysis has been studied * BRAF * RAS genes * KRAS * NRAS * HRAS * RET * RET/PTC1 * RET/PTC3 * PAX8/PPARgamma These have a reported high specificity for thyroid malignancy but a low sensitivity * they may be considered aas a "rule in test" but a negative result does not preclude a malignant diagnosis * they are therefore not routinely recommended currently

Answer 175

The Nottingham Prognostic Index * Calculated by * 0.2 x tumour size in cm * plus * grade (1-3) * plus * number of nodes * 0 = 1 * 1-3 = 2 * \>3 = 3 * general interpretation is in 10 year survival * \<3.4 over 90% * 3.4 to 5.4 over 75% * \>5.4 under 55%

Breast, endocrine, head and neck Flashcards

(211 cards)