head and neck, endocrine, breast Flashcards
(146 cards)
1
Q
neck anatomy
1) borders of the anterior neck triangle
2) borders of posterior neck triangle
3) which contains the carotid sheath
4) which contains the accessory nerve and brachial plexus
5) what does the accessory nerve inervate
6) location of false vocal cords in relation to true vocal cords
7) composition of the trachea anterior and posterior
A
1) sternocleidomastoid muscle (SCM), sternal notch, inferior border of digastric muscle
2) posterior border of the SCM, trapezius muscle and clavicle
3) anterior neck triangle
4) posterior neck triangle
5) SCM, trapezius, platysma
6) false cords are superior to true cords
7) U-shaped cartilage and posterior portion that is membranous
2
Q
What do they secrete
1) parotid glands
2) sublingual glands
3) submandibular glands
A
1) mostly serous fluid
2) mostly mucin
3) 50/50 serous/mucin
3
Q
neck anatomy
1) what does the vagus nerve run between
2) where does the phrenic nerve run
3) where does the long thoracic nerve run
A
1) bw Internal jugular vein and carotid artery
2) on top of anterior scalene muscle
3) posterior to middle scalene muscle
4
Q
Head anatomy 1) Trigeminal nerve a-branches b-actions 2) Facial nerve a-branches b-actions 3) Glossopharyngeal nerve a-actions b-what does injury affect 4) hypoglossal nerve a-actions b-findings in hypoglossal nerve injury 5) recurrent laryngeal nerve- innervates all of larynx except what muscle? what nerve innervates that muscle
A
1) a-ophthalmic, maxillary, and mandibular branches
b- sensation to most of face. mandibular branch supplys taste to anterior 2/3 of tongue, floor of mouth and gingiva
2) a-temporal, zygomatic, buccal, marginal mandibular and cervical branches (to zanzibar by motor car)
b-motor function to face
3) a-taste to posterior 1/3 of tongue, motor to stylopharyngeus
b-swallowing
4) a-motor to all of tongue except palatoglossus
b-tongue deviates to the same side of the injury
5) innervates all of larynx except cricothyroid which is innervated by superior laryngeal nerve
5
Q
Frey’s syndrome
1) after what surgery does it occur
2) what nerve is injured
3) resulting symptoms
A
1) after parotidectomy if injury of (2)auriculotemporal nerve-> cross-innervates with sympathetic fibers to sweat glands of skin-> gustatory sweating (sweating on cheek area when eats or smells or thinks of food)
6
Q
Name the branches of the thyrocervical trunk in the order that they branch off after it leaves the subclavian artery
A
STAT= 1st- suprascapular artery; 2nd-transverse cervical artery, 3rd- ascending cervical artery, 4th-inferior thyroid artery
7
Q
what does the superior thyroid artery come from
A
1st branch of the external carotid artery
8
Q
what artery is the
1) trapezius flap based on
2) pectoralis major flap based on
A
1) transverse cervical artery (2nd branch of thyrocervical trunk)
2) either the thoracoacromial artery or the internal mammary artery
9
Q
Describe what they are and rx
1) Torus palatini
2) Torus mandibular
A
1) congenital bony mass on the upper palate of mouth. no rx.
2) same as 1 but on lingual surface of mandible. no rx.
10
Q
What do you take in a:
1) Modified radical neck dissection
2) radical neck dissection
3) what is the mortality difference between the two
A
1) takes omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and ipsilateral thyroid
2) same as above + accessory nerve (CN XII), SCM, and internal jugular resection. (rarely done)
3) no mortality difference, but most morbidity occurs from accessory nerve resection so RND rarely done
11
Q
Oral cavity CA- mouth floor, anterior 1/3 tongue, gingiva, hard palate, anterior tonsillar pillars and lips
1) MC CA of the oral cavity, pharynx and larynx
2) biggest risk factors
3) difference between erythroplakia and leukoplakia
4) MC site for oral cavity CA
5) what location of tumor is the survival rate lowest
6) rx
A
1) Squamous cell cancer
2) Tobacco and ETOH
3) erythroplakia (flat red patch/lesion on mouth) considered more premalignant than leukoplakia (white patch)
4) lower lip
5) hard palate tumors-hardest to resect
6) wide resection (1cm margin)
- for tumors >4cm, clinically positive noses or bone invasion do MRND
- Do postop XRT for lesions >4cm, positive margins, or nodal/bone involvement
12
Q
Oral Cavity CA 1) Lip CA a- which lesions are most aggressive b- when do you need flaps 2) T/F- In tongue CA you can still operate with jaw invasion? If true, name the procedure 3) Verrucous ulcer a-what is it b-where is it found c-risk factor d-rx
A
1) a-lesions along the commissure are most aggressive
b-need flap if >1/2 of lip is removed
2) True. Commando procedure.
3) a-well-differentiated SCC, not aggressive, rare metastasis
b-cheek
c-oral tobacco
d-full cheek resection +/- flap. no MRND!
13
Q
Oral Cavity Ca 1) rx of maxillary sinus CA 2) Tonsillar CA a-risk factors b-MCC type c- prognosis d-rx
A
1) maxillectomy
2) a-ETOH, tobacco, males
b-SCC
c- pts asx until large so 80% have LN met at time of d- rx- tonsillectomy best way to bx, then wide local resection with margins after that
14
Q
Pharyngeal CA
1) Nasopharyngeal SCC
a- risk factors and presentation
b- where does it spread to
c- rx
2) #1 tumor of nasopharynx in kids and rx
3) MC benign neoplasm of nose/paranasal sinuses
A
1) a- EBV, Chinese. presents with nose bleed or obstruction
b- posterior cervical neck nodes
c-XRT primary therapy (with chemo for advanced disease). NO SURGERY
2) lymphoma. rx- chemo
3) papilloma
15
Q
Pharyngeal CA 1)Oropharyngeal SCC a- sx b- where does it spread c-rx 2) Hypopharyngeal SCC a- sx b-where does it spread c-rx
A
1) a-neck mass, sore throat
b-posterior cervical neck nodes
2) a-hoarseness; EARLY metastases
*c for both: XRT for tumors <4cm and no nodal or bone invasion. Combined surgery MRND, and XRT for more advanced tumors
16
Q
Pharyngeal CA 1_ Nasopharyngeal angiofibroma a-prognosis b-population and sx c-rx
A
1) a- benign tumor
b- males <20yo with obstruction or epistaxis
c-angio and embolization (usually internal maxillary artery), followed by resection
17
Q
Laryngeal CA
1) sx
2) rx
3) MC benign lesion of larynx
A
1) hoarseness, aspiration, dyspnea, dysphagia
2) XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord). Surgery is not primary treatment bc try to preserve larynx, but MRND (includes ipsilateral thyroid lobe) needed if nodes clinically positive.
3) papilloma
18
Q
Salivary Gland CA- parotid, submandibular, sublingual and minor salivary glands 1) Benign of Malignant. a- Mass in large salivary gland b- Mass in small salivary gland c- MC site for malignant tumor 2) Malignant tumors a- presentation b- site of lymphatic drainage c- rx 3) Top 2 malignant tumors of the salivary glands and characteristics and which is v sensitive to XRT
A
1) a- benign
b) malignant
c- Parotid gland (even though it is large)
2) a-painful mass, facial nerve paralysis or lymphadenopathy
b-intra-parotid and anterior cervical chain nodes
c- resection of salivary gland (ie-total parotidectomy), prophylactic MRND and postop XRT if high grade or advanced disease
3) mucoepidermoid CA (#1)- wide range of aggressiveness
Adenoid cystic CA (#2)- long, indolent course, propensity to invade nerve roots, very sensitive to XRT
19
Q
Salivary Gland TUmors
1) benign tumors
a- presentation
b-MC benign tumor, malignant potential and rx
c-Warthin’s tumor (submandibular duct)- who gets it, % bilateral and rx
d-MC salivary gland tumor in children
A
1)a- painless mass
b- Pleomorphic adenoma (mixed tumor), malignant degeneration in 5%. rx- superficial parotidectomy. if malignant need total parotidectomy
c- males, bilateral in 10%. rx- superficial parotidectomy
d-hemangiomas
20
Q
1) MC injured nerve with parotid surgery and resulting deficit
2) what nerves do you need to find for submandibular resection
A
1) greater auricular nerve-> numbness over lower ear
2) find mandibular branch of facial nerve, lingual nerve and hypoglossal nerve
* branches of facial nerve course bw superficial and deep parotid. Main trunk of facial nerve at level of digastric muscle
21
Q
Ear-
1) how to rx Pinna lacerations
2) what is cauliflower ear and how to rx
3) what is cholesteatoma, presenting sx and rx
4) Chemodectomas- what are they and rx
A
1) suture through involved cartilage
2_ undrained hematomas that organize and calcify. need to be drained to avoid this
3) epidermal inclusion cyst of ear, slow drowing but erode. sx- progressive hearing loss and clear drainage from ear. rx- surgica excision
4) vascular tumor of middle ear (paraganglionoma). rx- surgery +/- XRT
22
Q
Ear 1) acoustic neuroma a- nerve effected b- sx c- where can it grow into d- rx 2) Ear SCC a- where do they metastasize b-rx 3)MC childhood aural malignancy of middle or external ear
A
1) a-CNVIII
b- tinnitus, hearing loss, unsteadiness
c- cerebellar/pontine angle
d-craniotomy and resection. XRT is alternative to surgery
2) a- 20% met to parotid
b- resection and parotidectomy, MRND for positive LN or large tumor
3) Rhabdomyosarcoma
23
Q
Nose 1) when to set nasal fx 2) rx of septal heamtoma 3) rx of epistaxis 4) CSF rhinorrhea a-MC cuase b-what protein is in CSF c-how to find leak d-rx
A
1) after swelling decreases
2) drain to avoid infection and necrosis of septum
3) 90% are anterior- pack. for persistent posterior bleeding despite packing/balloon, consider internal maxillary artery or ethmoid artery embolization
4) a-cribiform plate fracture
b- tau protein
c-can use contrast study to help find leak
d-can repair facial fx. may help. Try conservative rx 2-3 weeks, try epidural catheter drainage of CSF. may need transethmoidal repair
24
Q
Neck and jaw
1) what is a radicular cyst, appearance on x-ray, and how to rx
2) Ameloblastoma- what is it, appearance on x-ray and how to rx
3) osteogenic sarcoma- prognosis and rx
4) rx of maxillary jaw fx
5) rx of TMJ dislocation
A
1) inflammatory cyst at the root of teeth (can cause bone erosion). lucent on xray, rx-local excision or curratage
2) slow-growing malignancy of odontogenic epithelium (outside portion of teeth), soap-bubble appearance on CXR. rx- wide local excision.
3) poor prog. rx- multimodality including surgery
4) wire fixation
5) closed reduction
25
Neck and Jaw
1) nerve damaged when lower lip numbness
2) how to repair stensen's duct laceration, what is prbm with ligation?
1) inferior alveolar nerve damage (branch of mandibular nerve)
2) repair over catheter stent. ligation can cause painful parotid atrophy and facial assymetry.
26
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Neck and Jaw
1) Suppurative parotitis
a- MC age group
b-causes
c- rx
d- prognosis
```
1) a-elderly
b- dehydration, staph is MC organism
c-fluids, salivation, abx, drainage if abscess develops or pt not improving
d- can be life threatening
27
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Neck and Jaw
1) Sialoadenitis
a- what is it and cause
b- MC glands affected
c- cause of recurrent sialoadenitis
d- rx
```
1) a- acute infam of a salivary gland related to a stone in the duct; most calculi near the orifice
2) submandibular or sublingual glands, 80% of the time
3) ascending infection from oral cavity
4) incise duct and remove stone, gland excision may eventually be necessary
28
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head and neck abscesses
1) peritonsillar abscess
a- age group
b-sx
c- rxx
2) retropharyngeal abscess
a- age group
b-sx
c- what other pt population/disease do you see it in
d-rx
```
1) a- older kids >10yo
b- trismus, odynophagia, usually doesn't obstruct airway
c- needle aspiration 1st, then drainage through tonsilar bed if no relief in 24hr (may need to intubate to drain. Will self-drain with swallowing once opened)
2) a- younger kids s disease
d-intubate. drain through posterior pharyngeal wall, will self-drain with swallowing once opened
29
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head and neck abscesses cont.
1) Parapharyngeal abscess-
a- when do you see it
b- what causes it's morbidity
c- rx
2) ludwig's angina
a- what is it and what muscle is involved
b-rx
```
1) a- all age groups, occurs with dental infections, tonsillitis and pharyngitis
b- morbidity from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spaces
c- drain through lateral neck to avoid damaging internal carotid and internal jugular veins. NEED TO LEAVE A DRAIN
2) -acute infection of the floor of the mouth, involves mylohyoid muscle. MC cause is dental infection of the mandibular teeth
b- airway control (may spread rapidly to deeper structures and cause obstruction), surgical drainage, abx
30
Preauricular tumors
1) what are they
2) how to diagnose
3) rule of 80% for parotid tumors
4) MC distant met site for head and neck tumors
1) parotid tumors until proven otherwise
2) superficial lobectomy
3) 80% of salivary tumors are in the parotid, 80% of parotid tumors are benign, 80% of benign parotid tumors are pleomorphic adenomas
4) lung
31
Posterior neck masses
1) what is most likely cause
2) how to dx
1) if no obvious malignant epithelial tumor, considered to have hodgkin's lymphoma until proved otherwise
2) FNA or open biopsy
32
Neck mass workup
1) 1st step
2) next step if 1st step nondiagnostic
3) 3rd step if above two steps nondiagnostic
4) if dx reveals adenocarcinoma, what is the likely primary
1) H and P, laryngoscopy and FNA (best test for dx), can consider antibiotics for 2 weeks with re-evaluation if thought to be inflammatory
2) panendoscopy with multiple random biopsies and neck and chest CT
3) excisional biopsy (need to be prepared for MRND)
4) breast, GI or lung primary
33
Epidermoid CA
1) what is it
2) work up if found in cervical node without known primary (3 steps in order)
3) MC location for occult head/neck tumor
1) SCC variant
2) 1st- panendoscopy to look for primary with random bx's
2nd- CT scan
3rd- if still can't find primary, do ipsilateral MRND and tonsillectomy and bilateral XRT
3) ipsilateral tonsil
34
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Other head/neck conditions
1) esophageal forein body
a-MC location
b- dx and rx
c-what determines esophageal perforation risk
d- dx steps for pt with fever and pain after EGD for foreign body
2) laryngeal foreing body rx
3) sleep apnea
a- associated complications
b- who has it
c- rx
4) complication of prolonged intubation and how to rx
```
1) a- 95% just below the cricopharyngeus
b- rigid EGD under anesthesia
c-risk increases with length of time in esophagus
d- gastrografin followed by barium swallow to r/o perf
2) cough, may need emergent cricothyroidotomy as a last resort
3) a-MI, arrhythmia, death
b- obese, micrognathia, retrognathia (snoring and excessive daytime somnolence
c- CPAP, uvulopalatopharyngoplasty (best surgical solution), or permanent trach
4) subglottic stenosis. rx- tracheal resection and reconstruction
35
1) indications for tracheostomy and advantages
2) Median rhomboid glossitis- what is it and rx
3) cleft lip
a- which palate has defect/ structures involved
b- when to repair. what should you repair simultaneously
c- sx
4) cleft palate
a- which palate/structures
b- sx
c-when to repair
1) pts who will require intubation for >7-14 days. Decreases secretions, provides easier ventilation and decreases pneumonia risk.
2) failure of tongue fusion. no rx
3) a-primary palate. lips +/- alveolus
b- repair at 10 wks, 10lbs, Hgb 10. repair nasal deformities as well.
c-poor feeding
4) a-secondary palate- hard and soft palates
b- speech and swallowing can be affected if not closed soon enough. maxillofacial growth can be affected if closed too early
c- repair at 12 months
36
1) MC benign head/neck tumor in adults
2) Mastoiditis
a- what is it and why is it bad
b-what is it a complication of
c- signs
d- rx
3) Epiglottitis
a- why is it now rare
b- age affected
c- sx
d- rx
1) hemangioma
2) a-infection of mastoid cells-> can destroy bone
b- untreated acute supportive otitis media
c- ear pushed forward
d- abx, may need emergency mastoidectomy
3) a- caused by H. influenza type B and now there is the vaccine
b- mainly in kids 3-5yo
c- stridor, drooling, leaning forward position, high fever, throat pain, thumbprint sign on lateral neck film. Can cause airway obstruction
d- rx- early control of airway and abx
37
Endocrinology
1) what does hypothalamus release and where does it go
2) what does dopamine inhibit the secretion of
3) what does the posterior pituitary secrete and where are they produced
4) what does the posterior pituitary release
1) TRH, CRH, GnRH, GHRH and dopamine into median eminence-> passes through neurohypophysis (posterior pituitary) on way to adenohypophysis (anterior pituitary)
2) prolactin
3) Neurohypophysis- ADH (supraoptic nuclei), Oxytocin (paraventricular nuclei in hypothalamus)
4) ACTH, TSH, GH, LH, FSH, prolactin
38
Pituitary
1) which part does not contain any cell bodies
2) which part does not have its own direct blood supply
3) what regulates ADH release
4) what part of pituitary comprises 80% of the gland
1) posterior pituitary/neuohypophysis
2) anterior pituitary/adenohypophysis (passes thorugh neurohypophysis 1st (portal venous system)
3) osmolar receptors in hypothalamus
4) anterior pituitary
39
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Pituitary Masses
1) Cause of bi-temboral hemianopia
2) Nonfunctional tumors
a- what are they usually
b- how do they present
c- rx
3) C/I to transsphenoidal resection
4) chemical rx of pituitary tumors
5) MC pituitary adenoma
```
1) pituitary mass compresses optic nerve (CN II) at the chiasm
2) a-macroadenomas
b- mass effect, decreased ACTH, TSH, GH, LH, FSH
c- transsphenoidal resection
3) suprasellar extension, massive lateral extension, dumbbell-shaped tumor
4) bromocriptine
5) prolactinoma
40
Prolactinoma
1) MC size
2) prolactin levels at which sx occur
3) sx
4) rx
5) what is rx in pregnancy
6) complications of resection of macroadenoma
1) microadenoma
2) >150
3) galactorrhea, irregular menses, decreased libido, infertility
4, 5) bromocriptine (safe in pregnancy) or cabergoline (both are dopamine agonists),
If fail medical rx- transphenoidal resection
6) hemorrhage, visual loss, CSF leak, don't do if pt wants pregnancy
41
Acromegaly
1) hormone involved
2) sx
3) MC tumor size
4) how to dx
5) rx
1) Growth hormone
2) HTN, DM, gigantism. can be life-threatening 2/2 cardiac sx (valve dysfnc or cardiomyopathy)
3) macroadenoma
4) elevated IGF-1 (best test), growth hormone >10 in 90%
5) octreotide or transsphenoidal resection, XRT and bromocriptine can be used as secondary therapies
42
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1) Sheehan's syndrom
a- 1st sign
b- other sx
c- cause
d-rx
2) Craniopharyngioma
a- what is it and what is it a remnant of
b- sx
c- rx
d- frequent post-op complication
```
1) a- post-partum trouble lactating
b- amenorrhea, adrenal insufficiency and hypothyroidism
c0 2/2 pituitary ischemia following hemorrhage and hypotensive episode during childbirth
d- hormone replacement
2) a- benign calcified cyst, remnants of rathke's pouch; grows along pituitary stalk to suprasellar location
b- endocrine abnormalities, visual disturbances, HA, hydrocephalus
c- surgery to resect cyst
d- diabetes insipidus
43
```
1) bilateral pituitary masses
a- what should you check
b- what is it most likely
2) Nelsons syndorme
a- complication of what surgery
b- sx
c- cause
d-rx
3) Waterhouse-Friderichsen syndrome- what causes it and resulting deficiency
```
1) check pituitary hormone axis. if ok probably metastasis
2) a- after bilateral adrenalectomy
b,c-inc CRH-> pituitary enlargement->amenorrhea and visual problems (bitemporal hemianopia)
and hyperpigmentation from beta-MSH (melanocyte-stimulating hormone), a peptide byproduct of ACTH
d- rx- steroids
3) adrenal gland hemorrhage after meningococcal sepsis infection --> adrenal insufficiency
44
Vascular supply to the adrenal gland
1) superior adrenal
2) middle adrenal
3) Inferior adrenal
4) what does to left adrenal vein drain into
5) what does the right adrenal vein drain into
1) inferior phrenic artery
2) aorta
3) renal artery
4) left renal vein
5) IVC
45
1) 2 parts of the adrenal gland and innervation for each
| 2) where does adrenal lymph drain to
1) adrenal cortex (no innervation), adrenal medulla (innervated by sympathetic splanchnic nerves)
2) lymph drainage to subdiaphragmatic and renal LNs
46
1) diagnostic workup for incidental adrenal mass on CT
2) rx of asymptomatic adrenal mass
3) followup of incidentaloma if not resected
4) MC mets to adrenal
5) rx of isolated met to adrenal
1) often benign, check for functioning tumor- urine metanephrines/VMA/catecholamines, urinary hydroxycorticosteroids, serum K with plasma renin and aldosterone levels
- consider CXR, colonoscopy and mammogram to check for primary tumor (lung, colon, breast)
- if pt has a cancer history with asx adrenal mass, need biopsy
2) surgery if ominous characteristics (non-homogenous), >4-6cm, functioning or enlarging. use anterior approach for adrenal CA resection.
3) repeat imaging q3mo for 1 year. then yearly imaging
4) lung CA (#1), breast, melanoma, renal CA
5) some can be resected with adrenalectomy
47
adrenal cortex
1) what does it develop from
2) name the 3 layers and what is produced in each
3) adrenal enzymes
4) descibe pathway of cortisol release from hypothalamus to adrenal
1) mesoderm
2) (GFR=salt, sugar, sex steroids)
Glomerulosa-aldosterone
fasciculata-glucocorticoids
reticularis- androgens/estrogens
3) 21- and 11-beta hydroxylase are in all zones
4) hypothalamus releases corticotropin-releasing hormone--> anterior pituitary gland--> ACTH release--> release of cortisol from adrenal gland
48
adrenal cortex
1) when is cortisol peak
2) actions of cortisol
3) actions of aldosterone
4) what stimulates aldosterone secretion
1) diurnal (daily) peak at 4-6am
2) ionotropic, chronotropic, increases vascular resistance, proteolysis and gluconeogenesis, decreases inflammation
3) stimulates renal sodium resorption and secretion of potassium and hydrogen
4) angiotensin II and hyperkalemia (ACTH also does to a small extent)
49
What should you think of if the adrenals are producing excess estrogens and androgens
cancer
50
Congenital adrenal hyperplasia
1) what pathway is the enzyme defect in
2) MC deficit and resulting change in hormones
3) other possible deficit
- which deficit is salt-saving vs salt-wasting and resulting effect on BP
4) treatment
1) cortisol synthesis
2) 21-hydroxylase deficiency-> inc 17-OH progesterone-> inc testosterone
* salt-wasting (hypoTN)
3) 11-hydroxylase deficiency-> inc deoxycortisone (mineralocorticoid)-> salt-saving (HTN)
4) cortisol, genitoplasty
51
Conn's syndrome- what is it
1) symptoms
2) what distinguishes between primary and secondary disease
3) Causes of primary disease
4) Causes of secondary disease
5) diagnosis
6) localizing studies
7) what are the pre-op considerations for these patients
Hyperaldosteronism
1) HTN 2/2 Na retention without edema, hypokalemia, weakness, polydypsia, polyuria
2) renin level- low in primary disease, high in secondary disease
3) #1=adenoma (85%), hyperplasia (15%), ovarian tumors and CA (rare)
4) more common than primary dz, 2/2 CHF, renal artery stenosis, liver failure, diuretics, Batter's syndrome (renin-secreting tumor)
5) salt-load suppresion test (best, urine aldosterone stays high
- aldosterone:renin ratio > 20 (labs: dec serum and urine K, inc serum Na, metabolic alkalosis
- plasma renin activity low
6) MRI, NP-59 scintigraphy (shows hyperfnc adrenal tissue) , adrenal venous sampling last resort
7) control HTN and K replacement
52
Hyperaldosteronism (Conn's syndrome)
1) rx of adenoma
2) rx of hyperplasia
3) what to give post op for BL adrenalectomy
1) adrenalectomy
2) seldom cured (inc morbidity with bilateral resection)
- medical rx 1st (spironolactone-inhibits aldosterone, Ca-channel blocker, potassium
- BL resection only done if refractory to med rx. must give fludrocortisone postoperatively
53
Addison disease-what is it
1) #1 cause
2) #1 primary cause of disease
3) other causes
4) diagnosis
hypocortisolism, adrenal insufficiency
1) withdrawal of steroids
2) autoimmune disease
3) pituitary disease, adrenal infection/hemorrhage/metastasis/resection
4) cosyntropin test-ACTH given, measure urine cortisol and remains low
- on labs will have low cortisol, high ACTH and low aldosterone
54
Addison disease/adrenal insuff/hypocortisolism
1) acute adrenal insuff sx
2) rx
3) chronic adrenal insuff sx
4) rx
1) hypotension, fever, lethargy, abdominal pain, N/V, dec glucose, inc K
2) dexamethasone, fluids, and give cosyntropin test (Dexamethasone dose doesn't interfere)
3) hyperpigmentation, weakness, weight loss, GI sx, inc K, dec Na
4) corticosteroids
55
Cushing's Syndrome- what is it
1) MC cuase
2) diagnostic flow chart
3) how to localize tumors and diff adrenal adenomas from hyperplasia
4) top-3 non-iatrogenic causes of cushing's
hypercortisolism
1) iatrogenic
2) 1st- measure 24-hr urine cortisol (most sensitive) and ACTH
--> if ACTH low (and cortisol high)= cortisol-secreting lesion (adrenal adenoma)
--> if ACTH high (and cortisol is hihg)= pituitary adenoma or ectopic source of ACTH (small cell lung CA)
2nd- if ACTH high, give high-dose dexamethasone suppresion test.
--> if urine cortisol suppressed= pituitary adenoma
--> if urine cortisol not suppressed--> ectopic producer of ACTH (ie-small cell lung CA)
3) NP-59 scintography
4) #1 Pituitary adenoma (80%), #2 Ectopic ACTH (ie-small cell lung CA), #3 adrenal adenoma
56
Discuss the differences in hormone/signaling mlq levels, diagnosis and the treatment for the following causes of hypercortisolism (Cushings)
1) Pituitary adenoma
2) Ectopic ACTH
3) Adrenal adenoma
4) Adrenal hyperplasia
1) mostly microadenomas, cortisol suppressed with dexameth-supp-test. dx- MRI vs petrosal sampling
rx- transphenoidal removal of tumor. if not possible- do XRT
2) cortisol not suppressed with dex-supp-test. dx- Chest and abdominal CT. rx- resection of primary if possible, if not medical suppression
3) dec ACTH, unregulated steroid production. rx- adrenalectomy
4) micro or macro. rx- metyrapone (blocks cortisol synthesis) and aminoglutethimide (inhibits steroid production). B/L adrenalectomy if medical management fails
57
When is b/l adrenalectomy indicated and what do you need to give postop if operating for cushings
pts with ectopic ACTH from tumor that is unresectable or ACTH from pituitary adenoma that can't be found.
for cushings- give steroids postop
58
Adrenocortical carcinoma
1) MC age and sex
2) what % are functioning tumors
3) signs/sx
4) what % have adv disease at time of dx
5) rx
6) 5-year survival
1) females, bimoral (<5yo and 5th decade)
2) 50% (cortisol, aldosterone, sex steroids)
3) children have virilization 90% of the time (precocious puberty in boys, virilization in females); feminization in men, masculinization in women, abdominal pain, weight loss, weakness
4) radical adrenalectomy, debulking helps symptoms and prolongs survival
* Mitotane (adrenal-lytic) for recurrent, residual or metastatic disease
5) 20%
59
Adrenal medulla
1) cell type that comprise it
2) hormone production and the rate limiting step
3) what converts norepinephrine to epinephrine and where is it found
4) T/F all pheochromocytomas produce norepinephrine
1) ectoderm neural crest cells
2) tyrosine-> dopa-> dopamine-> norepinephrine-> epinephrine
* RLS is tyrosine to dopa (Tyrosine hydroxylase)
3) PNMT (phenulethanolamine N-methyltransferase)
- only found in adrenal medulla (exclusive producer of epi)
4) False- only adrenal pheos produce epi
60
Adrenal Medulla
1) role of MAO (monoamine oxidase)
2) role of VMA (vanillylmandelic acid)
3) where are extra-adrenal nests of neural crest tissue sometimes found
1) breaks down catecholamines, converts norepinephrine to normetanephrine, epinephrine to metanephrine
2) produced from breakdown of catecholamines, can be used to check for pheo
3) retroperitoneum, most notably in organ of zuckerkandl at aortic bifurcation
61
Pheochromocytoma
1) cell type
2) where do they arise from
3) what is the 10% rule
4) what syndromes are they associated with
5) what side are they MC on
6) which types are most malignant
1) chromaffin cells
2) sympathetic ganglia or ectopic neural crest cells. rare, grow slowly
3) 10% are malignant, bilateral, in children, familial, extra-adrenal
4) MEN IIa and IIb, von Recklinghausen's dz, tuberous sclerosis, Sturge-Weber dz
5) right
6) extra-adrenal are more likely to be malignant
62
Pheochromocytoma
1) symptoms
2) how to dx and what test is C/I (why?)
3) rx and what is the first step in doing surgery
4) pre-operative preparation
1) HTN (often episodic), HA, diaphoresis, palpitations
2) urine metanephrines and VMA; VMA is most sensitive test
- MIBG scan (norepi analogue) can help identify location if having trouble finding tumor with CT/MRI
- Clonidine suppression test-- tumor doesn't respond, keeps catecholamines high
* NEVER do venography-> can cause hypertensive crisis
3) adrenalectomy- ligate adrenal veins first to avoid spilling catecholamines during tumor manipulation
- if unresectable can do tumor debulking
- Metyrosine- inhibits tyrosine hydroxylase-> dec catecholamine synthesis
4) volume replacement and alpha-blocker (phenoxybenzamine) first to avoid hypertensive crisis. then B-blocker if pt has tachycardia or arrhythmia
* if give b-blocker fist can get unapposed alpha-> hypertensive crisis, stroke and heart failure
- have Nirpride, Neo-synephrine and antiarrhythmic (ie-amiodarone) ready at surgery
63
Pheochromocytoma
1) post op conditions
2) other sites for the tumor
3) MC site of extramedullary tissue and tumors found in extramedullary tissue
4) other causes of falsely elevated VMA
1) persistent HTN, hypotension, hypoglycemia, bronchospasm, arrhythmias, intracerebral hemorrhage, CHF, MI
2) vertebral bodies, opposite adrenal gland, bladder, aortic bifurcation
3) organ of ZUckerkandl (inferior aorta near bifurcation) is MC. extra-med tissue responsible for medullary CA of thyroid and extra adrenal pheo
4) coffee, tea, fruits, vanilla, iodine contrast, labetalol, alpha and beta blockers
64
Ganglioneuroma
1) origin- cell type, organs
2) rx
1) rare, benign, asymptomatic tumor of neural crest origin in adrenal medulla or sympathetic chain
2) resection
65
Thyroid
1) what is the embryologic origin
2) Role of Thyrotropin-releasing factor (TRF)
3) role of thyroid-stimulating hormone (TSH)
4) how is TRF and TSH regulated by feedback
5) what does superior thyroid artery branch from
6) what about inferior thyroid artery?
7) what supplies the parathyroids and how do you avoid injury to parathyroid glands with thyroidectomy
1) from 1st and 2nd pharyngeal arches (not pouches)
2) released from hypothalamus--> anterior pituitary-->TSH release
3) released from anterior pituitary--> thyroid gland-> T3 and T4 release (involves cAMP)
4) negative feedback from T3/T4
5) 1st branch off external carotid artery
6) off thyrocervical trunk.
7) inferior thyroid artery. ligate close to thyroid to avoid injury to parathyroids
66
Thyroid
1) IMA artery- how often is it there? and where does it come from/go to
2) where does inferior thyroid vein drain
3) where does superior and middle thyroid veins drain
4)a- what does the superior laryngeal nerve innervate?
b-where does it run
c- result of injury
5) same as 4, but for recurrent laryngeal nerve
6) how common is a non-recurrent laryngeal nerve, which side is it MC on
7) T/F risk of injury is higher for non-recurrent laryngeal nerve during thyroid surgery
1) occurs in 1%, arises from innominate or aorta and goes to the isthmus
2) innominate vein
3) internal jugular vein
4)a- motor to cricothyroid
b- runs lateral to thyroid lobes, close to superior thyroid artery
c- loss of projection and easy voice fatigability (opera singers)
5) a-motor to all of larynx except cricothyroid
b-posterior to thyroid lobes in tracheoesophageal groove, can track with inferior thyroid artery
-Left RLN loops around aorta
-Right RLN loops around the innominate
c- hoarseness, if bilateral-> airway obstruction-> emergent tracheostomy
6) 2%, right side more common
7) True
67
Thyroid
1) what is ligament of Berry
2) role of thyroglobulin
3) T4:T3 ratio, which is more active and where is it produced
4) role of peroxidases
5) role of deiodinases
6) role of thyroxine-binding globulin
1) posterior medial suspensory ligament close to RLN, need careful dissection
2) stores T3 and T4 in colloid
3) 15:1. T3 is more active (tyrosine + iodine), produced in periphery from T4 conversion by deiodinases
4) link iodine and tyrosine
5) separate iodine from tyrosine
6) thyroid hormone transport, binds T3 and T4 in circulation
68
Thyroid
1) what is the most sensitive indicator of gland function
2) What are the tubercles of zuckerland. what nerve runs nearby and should you remove with thyroidectomy
3) what cells produce calcitonin
4) When to start thyroxine treatment? and what is long-term s/e
5) treatment for post-thyroidectomy stridor
1) TSH
2) most lateral, posterior extension of thyroid tissue. rotate medially to find recurrent laryngeal nerves. leave this portion with subtotal thyroidectomy 2/2 proximity to RLN
3) Parafollicular cells
4) if TSH levels fall 50%. osteoporosis is s/e
5) open neck and remove hematoma emergently to prevent airway compromis. If bl RLN injury need emergent tracheostomy
69
Thyroid Storm
1) symptoms
2) MC after surgery in pts with what undiagnosed dz
3) what can precipitate it
4) rx
5) describe the wolff-chaikoff effect
1) tachycardia, fever, numbness, irritability, vomiting, diarrhea, high-output cardiac failure (MC cause of death)
2) Graves' dz
3) anxiety, excessive gland palpation, adrenergic stimulants
4) Beta-blockers (1st line), PTU, lugol's solution (KI), cooling blankets, oxygen, glucose
* emergent thyroidectomy is rarely/never indicated
5) v. effective for thyroid storm- pt given high dose iodine (Lugol's soln, potassium iodide) which inhibits TSH action on thyroid and inhibits organic coupling of iodide-> less T3 and T4 release
70
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Asymptomatic thyroid nodule
1) % benign, MC sex
2) how to dx
3) rx if
a-follicular cells
b- thyroid CA
c-cyst fluid
d-colloid tissue
e- nl thyroid tissue but TFTs elevated
4) further testing if FNA indeterminate and rx
```
1) 90%, females
2) get FNA (1st test/best- determinant in 80%) and TFTs
3) a- lobectomy (10% risk of CA)
b- thyroidectomy or lobectomy + appropriate rx
c- drain. If recurs or bloody-> lobectomy
d- most likely colloid goiter. give thyroxine. if enlarges-> lobectomy
e- likely solitary toxic nodule. if asx-monitor. if sx- PTU and Iodine 131
4) for 20% indeterminant-> get radionuclide study
a-hot nodule->monitor if asx, PTU and I 131 if sx
b- cold nodule- lobectomy (more likley to be malignant)
71
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Thyroid Goiter
1) most identifiable cause and rx
2) cause if diffuse enlargement but no evidence of functional abnormality
3) when to operate and what procedure for nontoxic colloid goiter
4) where do the vessels originate in
a- substernal secondary goiter
b-substernal primary goiter
c- mediastinal thyroid tissue
```
1) iodine def. rx- iodine replacement
2) nontoxic colloid goiter
3) if causing airway compromise or suspicious nodule do subtotal or total thyroidectomy. subtotal has less risk of RLN injury.
4) a- superior and inferior thyroid arteries
b- innominate artery
c- substernal goiter extension likely
72
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Thyroid abnormalities
1) pyramidal lobe- where is it and how common
2) lingual lobe-
a- where is it
b-sx
c- malignancy risk
d-rx
e- T/F it is usually the only thyroid tissue in the pt's who have it
3) thyroglossal duct cyst
a- classic PE findings
b- why do we resect it
c- what else should you resect with the cyst and name of procedure
```
1) 10%, extends from isthmus toward thymus
2) a- thyroid tissue that persists in foramen cecum at base of tongue
b-dysphagia, dyspnea, dysphonia
c- 2% malignancy risk
d- thyroxine suppression, abolish with iodine 131
*resect if worried about CA or doesn't shrink after medical therapy
e- true- in 70% it is the only thyroid tissue
3) a- moves upward with swallowing
b-susceptible to infection, may be pre-malignant
c-take midportion or all of hyoid bone along with thyroglossal duct cyst (Sistrunk procedure)
73
Hyperthyroidism treatment
1) What pts are propylthiouracil (PTU) and methimazole good for
2) which treatment is safe with pregnancy
3) which treatment is good for pts who are poor surgical risks or unresponsive to PTU
4) PTU mechanism of action and s/e
1) good for young pts, small goiters and mild T3/T4 elevation
2) PTU
3) Radioactive Iodine (131 I)
4) inhibits peroxidases and prevents iodine-tyrosine coupling.
s/e- aplastic anemia, agranulocytosis (rare)
5) inhibits peroxidases and prevents iodine-tyrosine coupling
s/e- cretinism in newborns (crosses pacenta), aplastic anemia, agranulocytosis (rare)
74
Thyroidectomy for hyperpthyroidism
1) When should you operate?
2) best time to operate in pregnancy
3) what operation can you do to leave pt euthyroid
1) cold nodules, toxic adenomas or multinodular goiter unresponsive to medical therapy, pregnant pts not controlled with PTU, compressive sx
2) 2nd trimester (dec risk of teratogenic events and premature labor)
3) subtotal thyroidectomy
75
Grave's disease
1) is it hyper or hypothyroid?
2) MC sex
3) sx
4) cause/pathophysiology
5) diagnostic studies/labs
1) hyper (MC cause 80%)
2) women
3) exophthalmos, pretibial edema, a-fib, heat intolerance, thirst, inc appetite, weight loss, sweating, palpitations
4) IgG Ab to TSH receptor (long-acting thyroid stimulator=LATS or thyroid-stimulating immunoglobuli
5) decreased TSH, inc T3/T4. LATS level, inc 123-I uptake on thyroid scan diffusely in thyrotoxic pt with goiter
76
Grave's Disease Treatment
1) medical options
2) when to operate
3) pre-op preparation required for pt
4) what are operation choices and cons of each
1) thiamides=PTU (50% recurrence), radioactive iodine 131 (5% recurrence). do medical management first
2) if medical manage fails or suspicious nodule, children, or pregnant pt not managed with PTU
3) PTU until euthyroid, beta-blocker, Lugol's solution for 14days to decrease friability and vascularity to be started once euthyroid
4) bilateral subtotal (5% recurr) or total thyroidectomy (need lifetime thyroxine treatment)
77
Toxic Multinodular goiter
1) hypo or hyperthyroid?
2) sex
3) sx
4) Pathophysiology
5) rx
!)hyper
2) women, >50yo, usually nontoxic first
3) tachycardia, weight loss, insomnia, airway compromise. Sx can be precipitated by contrast dyes
4) caused be hyperplasia 2/2 chronic low-grade TSH stimulation
5) Surgery is preferred initial treatment, but can consider trail of radioactive iodide 131 esp in frail or elderly if no compressing or suspicious nodule
78
Single Toxic thyroid nodule
1) hyper or hypothyroidism
2) sex and age
3) size at which sx occur
4) dx
5) rx
1) hyper
2) women, younger
3) >3cm to be sx; function autonomously
4) thyroid scan (hot nodule)- 20% eventually cause sx
5) thioamides and 131-I (95% effective); lobectomy if medical rx ineffective
79
Hashimoto's thydroiditis
1) hypo or hyperthyroid?
2) sx
3) sex
4) risk factors
5) what can it cause in the acute early stage
6) pathophysiology
7) pathology
8) rx
1) MC cause of hypothyroidism
2) enlarged gland, painless, chronic thyroiditis
3) women
4) h/o childhood XRT
5) thyrotoxicosis
6) caused by both humeral and cell-mediated autoimmune disease (microsomal and thyroglobulin Ab). Goiter 2/2 lack of organification of trapped iodide inside gland.
7) lymphocytic infiltrate
8) 1st line- thyroxine. Partial thyroidectomy if continues to grow despite thyroxine treatment, if nodules appear or if compression.
80
Bacterial thyroiditis
1) hypo or hyper
2) pathophysiology
3) signs/sx/TFTs
4) rx
1) hypo
2) usually 2/2 contiguous spread. MC is bacterial URI (staph/strep)
3) normal TFTs, fever, dysphagia, tenderness
4) abx. may need lobectomy to r/o CA in pts with unilateral swelling and tenderness. May need total thyroidectomy for persistent inflammation
81
DeQuervain's thyroiditis
1) hyper or hypothyroid?
2) sx and labs
3) typical precursor
4) rx
1) can be hyperthyroid initially then hypothyroid
2) elevated ESR, tender thyroid, sore throat, mass, weakness, fatigue, women
3) viral URI
4) steroids and ASA.
- may need lobectomy to r/o CA in pts with unilateral swelling and tenderness
- may need total thyroidectomy for persistent inflammation
82
Riedel's Fibrous struma of thyroid
1) what is it
2) typical symptoms
3) associated diseases
4) rx
1) woody, fibrous component that can involve adjacent strap muscles and carotid sheath, can resemble thyroid CA or lymphoma (need bx)
2) hypothyroidism, compression
3) sclerosing cholangitis, fibrotic diseases, methysergide Tx, and retroperitoneal fibrosis
4) rx- steroids and thyroxine. May need isthmectomy or tracheostomy for airway sx. if resection needed watch for RLNs
83
Thyroid Cancer
1) T/F: MC endocrine malignancy in US
2) follicular cells on FNA- % chance of malignancy and why
3) signs that are concerning for malignancy
4) what should you think about with sudden thyroid growth?
5) Follicular adenomas
a- cancer risk
b- make up
6) MC type of thyroid CA
7) which type is associated with MEN IIa or IIb
8) what is the most aggressive thyroid CA
1) true
2) 5-10% chance. unable to differentiate between follicular cell adenoma, follicular cell hyperplasia and follicular cell CA on FNA.
3) solid, solitary, cold, slow growing, hard; male, age >50, previous neck XRT, MEN IIa or IIb
4) hemorrhage into previously undetected nodule or malignancy
5) a- benign, no increased risk, but must remove to prove just an adenoma
b- colloid, embryonal, fetal
6) papillary thyroid CA
7) medullary thyroid CA
8) anaplastic thyroid CA
84
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papillary thyroid carcinoma
a- prognosis
b- risk factors
c- what predicts worse prognosis
d- T/F: prognosis is based on lymph spread
e- where does it metastasize to?
f-T/F: adults are more likley to be node positive than children
g-pathology
h-rx
```
a- least aggressive, slow growing, best prognosis, 95% 5-yr survival. death 2/2 local dz
b-women and children, childhood XRT (MC tumor following XRT)
c-older age >40-50yo
d- false.. lymphatic spread 1st but is not prognostic. prognosis based on local invasion
e- lung (rare)
f-False. Children are more likely than adults
g-psammoma bodies (Calcium) and Orphan Annie nuclei, many are multicentric
h- rx:* if minimal/incidental ( lobectomy.
*TOTAL thyroidectomy for b/l lesions, multicentricity, h/o XRT, positive margins of tumors >1cm
*Ipsilateral MRND- if clinically positive nodes or extrathyroidal tissue involvement
*Radioactive Iodine (I-131)-4-6 wk sp surgery if mets, residual local dz, positive LN or capsular invasion.
*XRT only for unresectable dz not responsive to I-131
85
Enlarged lateral neck LN that shows normal-appearing thyroid tissue
1) what is it
2) rx
1) Papillary thyroid CA with lymphatic spread (lateral aberrant thyroid tissue)
2) total thyroidectomy and MRND; 131-I 4-6wks post-op
86
Follicular thyroid CA
1) type of spread and MC site
2) what % have mets at diagnosis
3) FNA with follicular cells only- % chance of malignancy and rx
4) rx
5) prognosis
1) Hematogenous spread (bone most common)
2) 50% (more aggressive than thyroid papillary cell CA
3) 10% chance of malignancy, need lobectomy
4) lobectomy- if shows adenoma of follicular cell hyperplasia no other rx
* if follicular CA-> total thyroidectomy for lesions >1cm or extrathyroidal dz
* need ipsilateral MRND if clinically positive cervical nodes or extrathyroidal tissue involved.
* I-131 for lesions>1cm or extrathyroidal disease (4-6wk after surgery
5) 50% 5-year survival, prognosis based on stage
87
Medullary thyroid cancer
1) usually the first manifestation of what syndromes
2) cell type and what does it secrete and resulting symptoms
3) pathology
4) what else do you need to screen for in pts with this CA?
5) how does it spread?
6) early mets to where?
7) rx
8) how can you monitor for dz recurrence?
9) prognosis
1) MEN IIa or IIb (diarrhea)
2) parafollicular C cells- secrete calcitonin- can cause flushing and diarrhea
3) amyloid deposition
4) hyperparathyroidism and pheochromocytoma
5) lymphatic- most have involved nodes at the time of diagnosis
6) lung, liver, bone
7) rx- total thyroidectomy with central neck node dissection
*MRND if clinically positive nodes or if extrathyroidal dz present
for MEN IIa (at 6yo) and MEN IIb (at 2yo) do prophylactic thyroidectomy and central node dissection
*can't cure if liver or bone mets so don't attempt
*XRT for nonresectable local and distant mets
8) calcitonin levels
9) 50% 5-yr survival, based on presence of regional and distant mets (more aggresive than follicular and papillary CA)
88
Hurthle cell Carcinoma
1) prognosis
2) where it mets to
3) rx
1) most are benign (Hurthle cell adenoma), presents in older pts
2) mets go to bone and lung if malignant
3) total thyroidectomy, MRND for clinically positive nodes
89
Anaplastic thyroid CA
1) pt population seen in
2) prognosis
3) rx
1) elderly pts with long-standing goiters
2) rapidly leathal (0% 5-yr survival), usually beyond surgical management at time of diagnosis
3) total thyroidectomy if resectable (rare), can do palliative thyroidectomy for compressive sx or do chemo-XRT
90
What thyroid cancers is XRT effective for
papillary, follicular, medullary, and hurthle cell thyroid CA
91
Radioactive Iodide treatment (I-131)
1) what thyroid CA is it effective for
2) can it cure mets?
3) when should you give it in relation to surgery?
4) when should you thyroid replacement in relation to I-131? and what does it do?
5) side effects
6) indications for use
1) papillary and follicular ONLY
2) bone and lung mets yes
3) 4-6 wk after surgery when TSH levels highest
4) give thyroid replacement (thyroxine) after I-131 bc it would suppress TSH and uptake of I-131 if given before. It supresses TSH and slows metastatic disease
5) sialoadenitis, GI sx, infertility, bone marrow suppression, parathyroid dysfunction, leukemia
6) recurrent CA, primary inoperable tumor 2/2 local invasion, tumor >1cm or extrathyroidal dz (if metastatic dz need to do total thyroidectomy first so that I-131 taken up by metastatic lesions
92
Parathyroid anatomy
1) embryologic origin of
a) superior parathyroids and what is it associated with
b) location
c) inferior parathyroids and what is it associated with
d) location
2) blood supply to superior and inferior parathyroid
1) a-4th pharyngeal pouch (associated with thyroid complex)
b- lateral to recurrent laryngeal nerves (RLNs), posterior surface of superior portion of gland, above the inferior thyroid artery
c- 3rd pharyngeal pouch, associated with thymus
d- medial to RLNs, more anterior, below inferior thyroid artery. However, more variable locations and more likely to be ectopic (ie-tail of thymus MC, anterior mediastinum, intrathyroid, tracheoesophageal groove)
2) Inferior thyroid artery
93
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effect on serum Ca and PO4 of:
1) PTH
2) Vitamin D
3) Calcitonin
4) Normal levels of
a- Ca; b-PTH; c-PO4; d-Cl
```
1) In Kidney- increases serum Ca reabsorption in distal convoluted tubule, decreases PO4 reabsorption
In bowel-inc Vit D production in kidney (Inc 1-OH hydroxylation)-> inc Ca-binding in intestine-> inc Ca reabsorption
In bone- inc osteoclasts to release Ca and PO4
2) inc intestinal Ca and PO4 absorption by increasing Ca-binding protein
3) decreases serum Ca (dec bone Ca resorption= osteoclast inhibition, and inc urinary Ca and PO4 excretion)
4) a-8.5-10.5 (iCa 4.4-5.5)
b-5-40 pg/ml
c- 2.5-5.0
d-98-107
94
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1) MC cause of hyperparathyroidism
Primary hyperparathyroidism
2) who gets it
3) cause
4) diagnostic labs: effect on Ca, PO4, Cl to PO4 ratio, renal cAMP, HCO3-
5) associated acid-base derrangement
6) symptoms if there
```
1) previous thyroid surgery
2) women, older age
3) autonomously high PTH
4) inc Ca, dec PO4, Cl-:PO4->33, inc renal cAMP, HCO3- excreted in urine
5) hyperchloremic metabolic acidosis
6) most have no sx, just incidental inc Ca on routine labs. Sx- muscle weakness, myalgia, nephrolithiasis, pancreatitis, PUD, depression, bone pain, pathologic fractures, AMS, constipation, anorexia. Can get HTN from renal impairment
95
What is Osteitis fibrosa cystica and with what dz is it found
Brown Tumors- bone lesions from Ca resorption, characteristic of hyperparathyroidism
96
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Primary Hyperparathyroidism
1) Indications for Surgery
2) what % of pts have
a-single adenoma
b- multiple adenoma
c- diffuse hyperplasia
d- parathyroid adenocarcinoma
3) treatment for each of #2
4) special considerations for rx in pregnancy
```
1) symptomatic dz, asymotomatic dz with Ca>13, dec Cr clearance, kidney stones, substantially dec bone mass or pregnancy
2) a- 80%, b- 4%, c-15% (pts with MEN I or IIa have 4-gland hyperplasia) d- v. rare, can get v. high Ca
3) a and b- resection + inspect other glands to r/o hyperplasia or multiple adenomas
c- resect 3.5 glands or total parathyroidectomy and autoimplant (don't bx all glands)
d- radical parathyroidectomy + take ipsilateral thyroid lobe
4) do surgery in 2nd trimestor. hyperCa increases risk of still birth if not resected
97
Interop considerations for parathyroidectomy
1) why do a frozen section
2) why check PTH levels
3) where to look for missing gland
4) what to do if can't find gland
5) where is MC location for gland at reop for a missing gland
1) can verify tissue
2) should go to less than 1/2 of preop value in 10minutes
3) inferiorly in thymus tissue, near carotids, vertebral body, superior to pharynx, thyroid
4) close and follow PTH. if still high, get sestamibi scan to localize
5) normal anatomic position
98
2 causes of hypocalcemia after parathyroidectomy and PTH and HCO3- levels in each
1) Bone hunger- normal PTH, decreased HCO3-
| 2) Aparathyroidism- decreased PTH, normal HCO3-
99
MC cause of
1) persistent hyperparathyroidism after parathyroidectomy
2) recurrent hyperparathyroidism
1) missed adenoma remaining in the neck
2) occurs after period of hypocalcemia or normocalcemia
- new adenoma formation
- tumor impants at original operation that have grown
- recurrent parathyroid CA
100
1) risks of reoperation after parathyroidectomy
| 2) what is sestamibi scan best for
1) inc risk of RLN injury and permanent hypoparathyroidism
2) preferential uptake by overactive parathyroid gland-> good for picking up adenomas but not 4-gland hyperplasia, best for picking up ectopic glands
101
Secondary Hyperparathyroidism
1) cause
2) results/harmful effect seen
3) rx
1) renal failure pts-> inc PTH in response to low Ca
2) ectopic calcification and osteoporosis
3) Ca supplement, Vitamin D, control diet PO4, PO4-binding gel, dec aluminum.
- surgery (total parathyroidectomy with autotransplant or subtotal parathyroidectomy) for bone pain (MC indication), fractures or puritis (80% relief)
102
Tertiary hyperparathyroidism
1) what pts/cause
2) lab values
3) rx
1) renal disease corrected with transplant but still overproduce PTH
2) same as primary hyperparathyroidism/hyperplasia
3) subtotal or total parathyroidectomy with autotranspalntation
103
Familial Hypercalcemic Hypocalciuria
1) labs
2) cause/defect
3) rx
1) increased serum Ca (9-11), normal PTH (30-60), decreased urine Ca (would be increased if hyperparathyroidism)
2) defect in PTH receptor in distal convoluted tubule of the kidney that causes increased Ca resorption
3) nothing, Ca not that high
104
Pseudohypoparathyroidism- cause
Defect in PTH receptor in kidney-> doesn't respond to PTH
105
Parathyroid CA
1) labs
2) MC site for mets
3) rx
4) prognosis and cause of death
1) inc Ca (extremely high), PTH, alk phos
2) lung
3) wide en block excision (parathyroidectomy and ipsilateral thyroidectomy)
4) 50% 5-year survival, mortality due to hypercalcemia
- recurrence in 50%
106
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MEN syndromes
1) inheritance
2) MEN I
a- three tumors and treatment
b- which is first to cause symtoms
c-which is most morbid
d- which do you need to treat first if simultaneous
3) MEN IIa
a-3 tumors
b- which is 1st to cause symtoms
c- which is MC to cause death
d- which do you need to treat first if simultaneous
4) MEN IIb
a-3 tumors
b- which is 1st to cause symtoms
c- which is MC to cause death
d- which do you need to treat first if simultaneous
5) what genes are involved in each syndrome
```
1) AD, 100% penetrance (derived from APUD cells=amine precursor uptake and decarboxylation)
2) Parathyroid hyperplasia (1st to cause sx. rx- 4-gland resection with autotransplantation); pancreatic islet cell tumor- MC is gastrinoma, 50% multiple 50% malignant, most morbid; pituitary adenoma (MC is prolactinoma- correct hyperparathyroidsm 1st if simultaneous tumors)
3) parathyroid hyperplasia, medullary CA of thyroid (nearly all pts, 1st to become symptomatic, #1 cause of death, sx-diarrhea, often B/L); pheochromocytoma (often B/L, nearly always benign). Correct pheo first if simultaneous tumors
4) medullary thyroid CA (diarrhea, often B/L, nearly all pts, 1st to cause sx, #1 cause of death), Pheo (often B/L/benign, treat first if simultaneous), mucosal neuromas, marfan's habitus, MSK abnormalities
5) MEN I- MENIN gene; MEN IIa and IIb-ret proto-oncogene
107
Hypercalcemia
1) causes
a) which type of diuretic can cause
b) what is milk-alkali syndrome
c) what granulomatous diseases cause
d) malignant causes
e) other causes
2) hypercalcemic crisis- cause and treatment
3) how to differentiate bw breast CA mets to bone, small cell lung CA and other hematologic malignancies by lab values
1) a-thiazide diuretics
b- excessive intake of milk and Ca supplements
c-TB and sarcoidosis
d-hematologic (25%)- lytic bone lesions; nonhematologic (75%)- CA that release PTHrP (small cell lung CA and breast CA)
e- hyperparathyroidism, hyperthyroidism, familial hypercalcemic hypocalciuria, immobilization, excess vitamin D
2) usually 2/2 surgery in pts with pre-existing hyperparathyroidism. rx- fluids (NS) and lasix (furosemide)
3) Breast CA mets and small cell lung CA release PTHrP-> hypercalcemia and increased urinary cAMP
hematologic malignancies cause bone destruction with hypercalcemia and low urinary cAMP
108
Mithramycin-
1) what does it treat
2) mechanism of action
3) side effects
1) hypercalcemia for malignancies or failure of conventional rx.
2) inhibits osteoclasts
3) liver, renal and hematologic S/E's
109
Breast Anatomy
1) what embryologic structure is it formed from?
2) what hormone is responsible for
a- duct development, b-lobular dev't
3) what hormone synergizes with estrogen and progesterone
4) what arteries supply the breast
1) ectoderm milk streak
2) a- estrogen, b- progesterone
3) prolactin
4) internal thoracic artery, intercostal arteries, thoracoacromial artery and lateral thoracic artery
110
Breast Cyclic changes- hormone responsible for:
1) increased breast swelling, growth of glandular tissue
2) increased maturation of glandular tissue
3) withdrawal causes menses
4) cause ovum release
5) lack of these after menopause result in atrophy of breast tissue
6) what does baston's plexus do?
7) where is lymph drainage to?
8) what is the N of TMN for disease in supraclavicular nodes?
9) MC cause of primary axillary adenopathy
10) what do cooper's ligaments do
1) estrogen
2) progesterone
3) progesterone
4) LH/FSH surge
5) estrogen and progesterone
6) valveless vein plexus allows direct hematogenous metastases of breast CA to spine
7) 97% axillary LN, 2% to internal mammary nodes (independent of breast quadrant)
8) N3
9) lymphoma
10) suspensory ligament, divides breast into segments. If breast CA affects, can dimple skin
111
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Breast nerves
1) long thoracic nerve
a- what does it innervate
b- what does injury result in
c- what does lateral thoracic artery supply
2) thoracodorsal nerve
a- what does it innervate
b-result of injury
c- what does thoracodorsal artery supply
3) medial pectoral nerve- what does it innervate
4) lateral pectoral nerve- what does it innervate
5) Intercostobrachial nerve
a- where does it branch off from
b- what does it innervate
c- where to find it
d- consequence of transection
```
```
1) a- serratus anterior
b-winged scapula
c- serratus anterior
2) a- latissimus dorsi
b-weak arm pull-ups and adduction
c- latissimus dorsi
3) pectoralis major and minor
4) pectoralis major
5) a- lateral cutaneous branch of 2nd intercostal
b- sensation to medial arm and axilla
c- just below axillary vein when doing ax dissection
d- no major consequence
```
112
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Benign breast dz
1) abscess
a- associated with
b- MC causes
c-rx
2) infectious mastitis
a- associated with
b-MC cause
c- possible cause in nonlactating women
d- rx
3) Periductal mastitis (aka mammary duct ectasia or plasma cell mastitis)
a- sx
b-risk factors
c- bx findings/ path
d- rx
```
1) a- breast feeding
b- staph #1, strep
c- stop breast feeding, breast pump, abx, I&D
2)a- breast feeding
b-staph
c- inflammatory (actinomyces) or autoimmune dz (SLE)
d- if nonlactating may need breast bx to r/o necrotic CA (incisional bx including skin). If lactating, continue to lactate, warm compress and analgesic. if not improved in 24hr start abx
3) a-noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple, can have sterile or infected subaleaolar abscess
b- smoking, nipple piercing
c- dilated mammary ducts, inspissated secretions, marked periductal inflamation
d- if creamy (non-bloody) discharge and no nipple retraction-> abx and reassure
if not or recurs, need to r/o inflammatory breast CA via incisional bx
113
Benign Breast Dz
1) Galactocele- what is it, when does it occur and rx
2) Galactorrhea: a) causes, b)common sx in females
3) Gynecomastia: a)causes, b) rx, c) how to determine it is there in males
4) neonatal breast enlargement: a) cause, b) rx
5) accessory breast tissue: a) where is it MC
6) where are accessory nipples found
7) what is frequently compromised with breast reduction
1) breast cyst filled with milk, occurs with breast feeding. Tx- aspirate or I&D
2) a) caused by increased prolactin (piruitary adenoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpine
b) amenorrhea
3) a- cimetidine, spironolactome, marijuana or idiopathic (MC)
b- likely will regress, can resect if cosmetic deforming or social problems
c-2-cm pinch
4) 2/2 circ maternal estrogen, will regress (no rx)
5) axilla
6) anywhere from axilla to groin (MC breast abnormality)
114
Benign Breast disease
1) Components of Poland's syndrome
2) Mastodynia
a) dx, b) rx, c) what should patients discontinue,
d) MCC of cyclic mastodynia, e) MCC of continuous mastodynia
3) Mondors disease-what is it
a) causes, b) location, c) rx
1) hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle
2) a) hx and PE, b/l mammogram
b) danazol, OCPs, NSAIDs, evening primrose oil, bromocriptine
c) caffeine, nicoteine, methylxanthines
d) fibrocystic disease
e) acute or subacute infection- more refractory to treatment
3) superficial vein thrombophlebitis of breast; feels cordlike, can be painful
a) trauma and strenuous exercise
b) usually in lower outer quadrant
c) NSAIDs
115
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Benign Breast disease
1) Fibrocystic disease
a- types
b-sx
c-which types have CA risk and rx
```
1) a- papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia and lobular hyperplasia
b- breast pain, nipple discharge (yellow-brown), lumpy breast tissue varies with hormonal cycle
c-atypical ductal or lobular hyperplasia- resect these lesions (with atypical hyperplasia don't need negative margins, just remove suspicious areas
116
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Benign Breast dz
1) Intraductal papilloma
a- sx
b- malignant potential
c- how to find and rx
```
1) a- bloody nipple discharge (MC cause), small, nonpalpable, close to nipple
b- NOT premalignant
c- get contrast ductogram to find then needle localization. rx- subareolar resection of involved duct and papilloma
117
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Benign Breast dz
1) Fibroadenoma
a-sx
b-path
c-mammogram findings
d-in pts under 40yo, what do you need to be able to just observe
e-rx in teenagers and younger children
f- rx in pts over 40yo
```
1) a- painless, slow-growing, well circumscribed, firm, rubbery mass (can be >5cm), can change with menstrual cycle and pregnancy
b- fibrous tissue compressing epithelial cells
c- large, coarse calcifications (popcorn lesions) on mammo from degeneration
d-need all 3 of the following:
-clinically benign feeling
-US or mammo consistent with fibroadenoma
-FNA or core needle bx shows fibroadenoma
*If not all 3 true, or continues to enlarge need excisional bx to ensure dx
e- avoid resection bc can affect breast development
f-excisional biopsy
118
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Nipple discharge
1) t/f: MC benign
2) dx
3) MC cause and rx for
a- Green discharge
b- Bloody discharge
c- Serous discharge
d-spontaneous discharge
4) management of nonspontaneous discharge
```
1) true
2) history, PE and b/l mammogram
3) a- fibrocystic disease. rx- if cyclic and nonspontaneous just reassure pt
b- MC intraductal papilloma but occas ductal CA- need ducotogram with excision of mass and duct
c- worrisome for CA- especially if only from 1 duct. rx-excisional biopsy of ductal area
d- worrisome for CA-> excisional bx of ductal area. May have to do complete subareolar resection if area cannot be properly identified.
e- nonspontaneous= occurs with pressure, tight graments, exercise etc. not as worrisome, may need excisional bx if bloody
119
Ductal Carcinoma in Situ (DCIS)
1) path/description
2) malignant potential
3) PE and mammogram findings
4) must aggressive subtype and rx
5) Criteria for increased recurrence risk
6) rx
1) malignant cells of ductal epithelium without invasion of basement membrane
2) considered premalignant, 50% get ipsilateral CA if not resected; 5% get contralateral CA
3) usually not palpable, mammo shows cluster of calcifications
4) Comedo pattern- has necrotic areas. rx- simple mastectomy bc high risk for multicentricity, microinvasion and recurrence
5) Comedo type or lesions>2.5cm
6) lumpectomy and XRT; need 1cm margins (NO ALND or SLNB), possibly tamoxifen
* * if high grade (comedo type, multicentric, multifocal) or not ammenable to lumpectomy/can't get good margins need to do simple mastectomy
120
Lobular carcinoma in situ (LCIS)
1) malignant potential
2) MC age of pt
3) MC type of CA associated with LCIS
4) rx and do you need negative margins?
1) not premalignant, but marker for malignancy- 40% get breast CA in either breast
2) premenopausal
3) ductal CA
4) nothing, tamoxifen or bilateral subcutaneous mastectomy. DON'T need ALND or negative margins
121
Which of the following is not an indication for surgical biopsy after core biopsy?
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Radial scar
Lobular carcinoma in Situ
columnar cell hyperplasia with atypia
fibrous tissue compressing epithelial cells in teenager
papillary lesions
lack of concordance bw mammo and histologic dx
nondiagnostic specimen
fibrous tissue compressing epithelial cells in a teenager= benign fibroadenoma
122
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Breast CA
1) what country has lowest rate
2) US breast CA risk
3) how much does screening reduce mortality?
4) what percent have negative mammo and US
5) typical clinical features
6) symptomatic breast mass wu in
a- 40years old
```
1) japan
2) 12% (1 in 8) of all women, 5% in women with no risk factors
3) 25%
4) 10%
5) distortion of normal architecture, skin/nipple distortion or retraction, hard/tethered/indistinct borders
6) a-need US and core needle bx. If clinical exam or US indeterminate or suspicious for CA need mammogram
b- need B/L mammogram, US and Core needle bx
*if Core Needle bx indeterminate, non-diagnostic or non-concordant with PE/imaging studies, need excisional bx for both
123
Breast CA
1) work up of cyst fluid- when do you need cyst excisional bx
2) difference bw FNA and core needle biopsy
3) mammography sensitivity and specificity and how big mass needs to be to be detected
4) mammographic findings that suggest CA
1) if cyst fluid is bloody, clear and recurs or complex cyst
2) Core bx gives architecture, FNA only gives cytology
3) 90% sensitivity/specificity, must be >5mm to detect
4) irregular borders, spiculated, multiple clustered, small, thin, linear, crushed-like and/or branching calcifications, ductal asymmetry, distortion of architecture
124
Management of breast masses based on FNA or CNbx- treatment if:
1) malignant
2) suspicious
3) atypia
4) nondiagnostic
5) benign
1) definitive therapy
2) surgical bx
3) surgical bx
4) repeat CNbx or surgical bx
5) possible observation if concordant, otherwise excisional bx
125
BI-RADS classification of mammographic abnormalities: describe the assessment and recommendation for each category 1-5
Category 1) negative- routine screening
2) benign- routine screening
3) probably benign- short-interval f/u mammo
4) suspicious (ie- indeterminate calcifications or architecture)- get CN Bx (definite probability of CA)
5) Highly suggestive of CA (suspicious calcifications or architecture)-> get CN bx, high prob of CA
126
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Management of:
1) BI-RADS 4 lesion and CN bx shows:
a- malignancy
b- nondiagnostic, indeterminate or benign and non-concordant
c- benign and concordant
2) BI-RADS 5 lesion and CNBx shows:
a-malignancy
b- any other finding
```
```
1)a- follow appropriate rx for diagnosis
b- needle localized excisional bx
c-6-mo fu mammo
2) a- follow appropriate rx
b- needle localized excisional bx
```
127
Breast CA screening recs
1) when to get mammos
2) high risk pt screening
1) every 2-3 years after age 40, then yearly after age 50
| 2) mammogram 10years before the youngest age of diagnosis of breast CA in first-degree relative
128
Breast Node levels
1) describe location of node levels I-III
2) location of Rotter's nodes
3) what level nodes should you take in an axillary LN dissection
4) T/F nodes are most imp prognostic factor
5) MC site for distant mets in breast CA
6) what tumor locations have increased risk of multicentricity
1) I-lateral to pectoralis minor; II- beneath/posterior to pec minor; III- medial to pec minor
2) bw the pec major and pec minor muscles
3) levels I and II (take level III if grossly involved)
4) true, survival is directly related to the number of positive nodes:
0 nodes=75% 5-year survival; 1-3nodes=60%; 4-10nodes=40%
5) bone (also goes to lung, liver, brain)
6) subareolar and central tumors
129
TMN definitions for breast CA
1) difference bw T1-4
2) diff bw N0-3
3) diff bw stage 0-IV
1) T15cm; T4 has direct extension into chest wall, skin edema or ulceration, satellite skin nodules or inflammatory carcinoma
2) N1 has 1-3 internal mammary nodes positive
N2 has 4-9 positive nodes
N3 has 10+ positive nodes
3) Stage 0 is Tis; stage IIa T0-1 with only 1node or T2 no nodes; stage IIb is T2N1 or T3N0; stage IIIa is any N2 or T3N1; stage IIIc is any N3; IV has distant met
130
Breast Cancer Risk- Classify the following as Greatly Increased risk (RR>4), Moderately increased (RR2-4) and lower increased risk (RR35yo
Greatly increased (RR4+)= BRCA gene with fam hx, 2+ relatives with premenopausal or b/l breast CA, DCIS, LCIS, fibrocystic disease with atypical hyperplasia
Moderately increased (RR2-4)= prior breast CA, radiation exposure, first degree relative with breast CA, age 1st birth >35yo
Slightly increased (RR<2)=nulliparity, proliferative benign disease, early menarche, ETOH use, obesity, late menopause, HRT
131
BRCA I and II
1) risk of the following CA in BRCA I/ II respectively
a-female breast CA
b-ovarian CA
c-male breast CA
2) besides mastectomy what other surgeries should you consider
3) how much is CA risk increased if 1st degree relative has B/L, premenopausal breast CA?
```
1) a- 60% lifetime risk for both
b-BRCA I- 40%; BRCA II- 10%
c-BRCA I-1%; BRCA II- 10%
2) TAH and BSO if BRCA + fam h/o breast CA
3) risk increased to 50%
```
132
When should you consider prophylactic mastectomy
BRCA gene +family hx; or LCIS
| + high anxiety, poor access to followup, difficult lesion or pt preference
133
Receptors
1) what women are positive ER/PR receptors more common in
2) Do PR or ER positive have better prog
3) what % is negative for both ER/PR
1) postmenopausal
2) PR is better, but together they are the best
3) 10% of breast CA is both ER and PR negative
134
Male breast CA
1) MC type
2) prognosis
3) risk factors
4) rx
1) ductal
2) poorer- most have late presentation with increased pectoral muscle involvement
3) XRT, steroids, family hx, Klinefelter's syndrome
4) modified radical mastectomy
135
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Ductal CA
1) what % of all breast CA
2) path characteristics of various subtypes
a- Medullary
b-Tubular
c- Mucinous
d- Scirrhotic
e- which has worse prognosis
3) rx
```
1) 85%
2) a- smooth borders, inc lymphocytes, bizarre cells
b- small tubule formations
c-produces mucin
d/e- worse prognosis
3) MRM or BCT with postop XRT
136
Lobular CA
1) what % of all breast CA
2) T/F: increased risk of B/l, multifocal and multicentric disease
3) what cell type confers worse prognosis
4) rx
1) 10%
2) true- doesn't form calcification, extensively infiltrative
3) signet ring cells
4) MRM or BCT with postop XRT
137
Inflammatory CA
1) what stage disease is it considered
2) prognosis
3) defining appearance characteristic
4) rx
1) T4 disease
2) very aggressive, median survival 36 mo
3) dermal lymphatic invasion-> peau d'orange lymphedema appearance, warm and erythematous
4) neoadjuvant chemo, then MRM, then adjuvant chemo-XRT
138
Surgical options for breast CA
1) when can you do subcutaneous mastectomy (simple mastectomy)
2) when can you do breast-conserving therapy (lympectomy + ALND or SLNB) + post op XRT)
- what size margin do you need
3) what is removed in modified radical mastectomy
4) absolute contraindications to breast conserving therapy
5) relative C/I to breast conserving rx
1) not in CA, only DCIS, LCIS or prophylactic bc leaves 1-2% of breast tissue
2) breast CA. need 1-cm margin
3) removes all breast tissue including the nipple areolar complex and axillary node dissection (level I)
4) 2+ primary tumors in separate quadrants, persistent positive margins after reasonable surgical attempt, pregnancy (can't do XRT- but if in 3rd trimester may be able to do and delay XRT to after birth), h/o XRT to area, diffuse malignant appearing microcalcifications
5) scleroderma, SLE, large tumor in small breast, large/pendulous breasts
139
Surgical options for breast CA
1) when to do SLNB and how do you find nodes.
2) complication of lymphazyrin blue dye
3) when to do Axillary LND
4) C/I to SLNB
5) what to do if no LN found using radiotracer/dye in attempted SLNB
6) what node levels do you take in ALND
7) complications of MRM
1) malignant tumors >1cm without clinically positive nodes. inject lymphazyrin blue dye or radiotracer into tumor
2) Type I hypersensitivity reaction
3) clinically positive nodes
4) pregnancy, multicentric disease, neoadjuvant therapy, clinically positive nodes, prior axillary urgery, inflammatory or locally advanced disease
5) do formal ALND
6) I and II
7) infection, flap necrosis, seroma
140
Complications of axillary lymph node disection (ALND)
1) if early sudden postop swelling
2) if swelling after 18months
3) if inner arm and lateral chest wall hyperesthesia
and how long to leave drains
infection, lymphedema, lymphangiosarcoma.
Axillary vein thrombosis- early postop sudden swelling
lymphatic fibrosis- swelling after 18months
Intercostal brachiocutaneous nerve injry- hyperesthesia of inner arm and lateral chest wall
leave drains until
141
XRT for breast CA
1) what dose to use
2) complications of
3) Contraindications to use
4) when to use XRT after MASTECTOMY
5) BCT with XRT
a) what margins do you need before XRT
b) local recurrence rate
c) rx for local recurrence
1) 5000 rads
2) edema, erythema, rib factures, pneumonia, ulceration, sarcoma, contralateral breast CA
3) scleroderma (severe fibrosis and necrosis if give xRT), previous XRT would exceed recommended dose, SLE (relative), active rheumatoid arthritis (relative)
4) >4nodes, skin or chest wall involved, positive margins, tumor >5cm (T3), extracapsular nodal invasion, inflammatory CA, fixed axillary nodes (N2) or internal mammary nodes (N3)
5) a) 1cm negative margins
b) 10%, usually within first 2 years postop, need to restage recurrence
c) need salvage MRM
142
Chemotherapy for breast CA
1) drug regimen
2) what patients with positive nodes don't need chemo? And what can these pts get instead?
3) which patients with negative nodes need chemo?
4) which patients get hormonal therapy?
5) T/F: both chemo and hormone therapy decrease recurrence and improve survival
6) how much does tamoxifen decrease risk of breast ca and what are s/e's?
1) taxanes (docetaxel or paclitaxel), adriomycin and cyclophosphamide for 6-12 weeks
2) Breast CA that has positive estrogen receptors in postmenopausal women is the only node positive disease that doesn't require chemo- give aromatase inhibitor (anastrozole) only.
3) All pts with negative nodes and mass>1cm need chemo except if ER positive CA. for ER positive and postmenopausal give aromatase inhibitor (anastrozole) only or if premenopausal- tamoxifen only)
* if
143
Breast Cancer
1) t/f: almost all women with recurrence die of disease
2) increased recurrences and metastases occur with ____________.
3) metastatic flare sx and rx
4) occult breast CA- presentation and rx
5) Paget's disease
a) presentation and dx
b) what malignancy/premalignancy do these pts have
c) rx
1) true
2) large tumors, positive nodes, negative receptors, unfavorable subtypes
3)sx- pain, swelling, erythema in metastatic areas.
rx- XRT (esp good for bone mets)
4) axillary mets with unknown primary. rx- MRM (70% have breast CA)
5)a- scaly skin lesion on nipple, bx- paget's cells
b- DCIS or ductal CA in breast
c- need MRM if cancer present, otherwise simple mastectomy including nipple-areolar complex with Paget's disease.
144
Cystosarcoma phylloides
1) what % are malignant and how to tell
2) how do they spread
3) path
4) rx
1) 10%, based on mutations per hpf (>5-10)
2) hematogenous (rare). No nodal mets
3) like giant fibroadenoma (stromal and epithelial elecments/mesenchymal tissue). Can be large.
4) WLE with negative margins. No ALND
145
Stewart-Treves syndrome
1) what causes it
2) what malignancy is pressent
3) classic presentation
1) chronic lymphedema 2/2 ALND
2) lymphangiosarcoma
3) dark purple nodule or lesion on arm 5-10years postop
146
breast mass during pregnancy
1) how to dx
2) rx/dx for cyst
3) rx/dx if solid
4) If breast CA what is the rx if
a) 1st trimester
b) 2nd trimester
c) 3rd trimester
5) effect on options for XRT
1) ultrasound first to avoid radiation. mammo and US don't work as well during pregnancy
2) drain and send FNA for cytology
3) perform core needle biopsy
4) a and b- MRM; c-MRM or if late lumpectomy with ALND and postpartum XRT
5) no XRT while pregnant, no breast feeding after delivery if getting XRT
