Emma Holliday for Surgery: Part VII Flashcards by Isaac McCool

First step in working up a thyroid nodule

Check TSH

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You check the TSH for a thyroid nodule, what next?

If low, do a RAIU scan to find the “hot nodule.” Excise it or kill it with radioactive iodide.

If normal, get an FNA

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FNA of your nodule is done. What next?

If benign, leave it alone.

If malignant, excise it and check pathology

If indeterminant, re-bx it or check a RAIU scan

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If the nodule comes back cold, what next?

Excise it, check pathology

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5 types of cold nodular pathologies

Papillary
Follicular
Medullary
Anaplastic
Thyroid lymphoma

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Pathology of papillary cold thyroid nodule

MC type, spreads via lymph, psammoma bodies

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What pre-disposes someone to a thyroid lymphoma

Predisposed by hashimotos

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Pathology of follicular cold thyroid nodule

Spreads via the blood.

Better excise the whole thing

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Pathology of Medullary cold thyroid nodule

Associated with MENII. Look for pheochromocytoma and hypercalcemia. You wil lsee amyloid and calcifications in pathology

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Pathology of Anaplastic cold thyroid nodule

80% mortality in first year. No bueno.

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4 functional versions on an adrenal nodule

Pheochromocytoma
Primary aldosteronism
Adrenocortical carcinoma
Cushing or silent cushing syndrome

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Features of Pheochromocytoma and how we test for it

HTN, catechol symptoms

Get urine and plasma-free metanephrines

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Features of primary aldosteronism and how we test for it

HTN, low K+ and low PRA

Plasma aldosterone-to-renin ratio

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Features and testing for adrenocortical carcinoma

Virilization or feminization

Get a Urine 17-ketosteroid

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Features and testing for cushings

Cushing symptoms or normal exam results otherwise

Test with an overnight 1-mg dexamethasone test

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If the adrenal nodule is less than 5cm and non functional, what do you do

Observe with CT scans every 6 months

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What if the adrenal nodule is greater than 6 cm or functional

Surgical excision.

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Causes of hypothyroidism and what we see in the patient and labs

Typically from thyroidectomy

We see perioral numbness, chvostek’s and Trousseaus due to low calcium

Labs: Low calcium, high phosphate and low PTH

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Presentation of hyperparathyroidism

Usually asymptomatic increase in calcium but can present with kidney stones, abdominal or psychiatric symptoms

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Labs for hyperparathyroidism

High calcium, low phosphate, high Vitamin D and high parathyroid hormone

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Diagnosing hyperparathyroidism

FNA of suspicious nodules. Can use Sestamibi scan

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Treating hyperparathyroidism:

Surgical removal of adenoma. If hyperplasia, remove all 4 glands and implant 1 in the forearm

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MEN 1

Pituitary adenoma, parathyroid hyperplasia, pancreatic islet cell tumor

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MEN 2a

Parathyroid hyperplasia, medullary thyroid cancer, pheochromocytoma

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MEN2b

Marfanoid, medullary thyroid cancer and pheochromocytoma

U/S vs MRI for working up a breast mass

U/S can tell if solid or cystic. MRI is good for eval dense breast tissue, evaluating nodes and determining recurrent cancer. –Best imaging for the young breast –U/S good for determining fibroadenoma/cysto-sarcoma phyllodes.

FNA vs. aspiration vs. cytology

Aspiration of fluid if cystic, FNA for cells if solid –Send fluid for cytology if its bloody or recurs x2

Symptoms of fibrocystic change and solutions to help with this

–Fibrocystic change: cysts are painful and change w/ menses. Fluid is typically green or straw colored. •Restrict caffiene, take vitamin E, wear a supportive bra

When do we do an excisional biopsy of breast tissue?

•Excisional biopsy if palpable or if fluid recurs

Risk factors for breast cancer

RF: BRCA1 or 2, person hxof breast cancer, nulliparity, endo/exogenous estrogen.

What do we do for DCIS?

Either excision w/ clear margins or simple mastectomy if multiple lesions (no node sampling) + adjuvant RT.

What do we do for LCIS

More often bilateral. Consider bilateral mastectomy only if +FH, hormone sensitive, or prior hxof breast cancer

What do we do for Infiltrating ductal/lobular carcinoma

–If small and away from nipple, can do lumpectomy w/ ax node sampling. Adjuvant RT. Chemo if node +. Tamoxifenor Raloxifen if ER + –Modified radical mastectomy w/ ax node sampling w/o adjuvant RT gives same prognosis.

What is Paget's Dz of breast and what do we do about it

Looks like eczema of the nipple. Do mammogram to find the mass.

Symptoms of inflammatory breast cancer

Red, hot, swollen breast. Orange peal skin. Nipple retratction

What do we do about basal cell carcinoma?

Shave or punch bx then surgical removal (Moh's)

Precursor lesion to squamos cell

Actinic keratosis or keratoacanthoma

How do we treat the keratosis before it becomes a squamos cell?

5FU or excision

How do we treat squamos cell carcinoma?

Excisional bx at edge of the lesion then wide local excision. Rads can be used for tough locations

Many forms of melanoma. What is the worst prognosis one and the best prognosis one?

Superficial spreading = best prog and is also the most common Nodular is poor prognosis.

This melanoma is on the palms, soles, mucous membranes in darker races

Acrolintiginous

Lentigo maligna is found where?

Melanoma on the head and neck, actually has a good prognosis

#1 prognostic indicator for melanoma?

Depth.

First step when we see melanoma?

FULL THICKNESS bx. Not just bx. Remember depth is the most important thing.

Treatment for melanoma

Excision with 1 cm margins if less than 1 mm thick. 2 cm margin if 1-4 mm thick. 3 cm margin if more than 4 mm thick.

These drugs may help after biopsy for melanoma

High dose IFN or IL-2 may help

This is often confused wit ha bruised muscle

soft tissue sarcoma

Dx sarcoma?

Biopsy. NOT AN FNA. Excisional if less than 3 cm, incisional otherwise.

Tx for sarcoma

Wide local excision or amputation + RT

First site for sarcoma to spread to

Lungs (hematogenously).

If sarcoma spreads to the lungs, do we start chemotherapy?

Not yet. You can do a wedge resection if this is the only met and the primary mass is under control.

Liposarcomas usually arise from:

99% DO NOT come from Lipomas.

Hard round mass on extremity:

Fibrosarcoma/Rhabdomyosarcoma/Lymphangiosarcoma

These masses can occur in areas of chronic lymphedema

Fibrosarcoma/Rhabdomyosarcoma/Lymphangiosarcoma

Rule of 7s for a neck mass

7 days is inflammatory 7 months is a cancer 7 years is congenital

Most commonly a neck mass is just a reactive lymph node. So first step:

Look at teeth, tonsils, etc for inflammatory lesion or process

If you find a lesion on inspection of a neck mass work up what do you do

Wait 2 weeks an FNA if still present

If lymph node is firm and rubbery :

Excisional bx, look for lymphoma

/in hodgkins lymphoma, what will we see on histo?

R-S cells. Lymphocyte predominance is a good prognostic indicator

In non-hodgkins, what are the good prognostic indicators on histology

nodular and well differentiated

Brancial vs thyroglossal duct cyst

Midline = Thyroglossal. Remove this surgically Anterior to SCM = branchial

If mass is spongy, diffuse and LATERAL to SCM what does this indicate?

Cystic hygroma 2/2 Turners, Downs, Klinefelters

Emma Holliday for Surgery: Part VII Flashcards

(62 cards)