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Flashcards in Head, Neck And Breast Surgery Deck (56):
1

List the non-hereditary risk factors for breast cancer

Older patient >50 years

Females

Alcohol and smoking

Early menarche

Late menopause

Late first pregnancy/few or no pregnancy

Obesity

2

List the hereditary risk factors for breast cancer

BRCA 1 or BRCA 2 mutation
* BRCA 1 mutation - 85% chance of developing breast ca

Family history of breast cancer

Family history of ovarian cancer

Personal history of breast cancer

3

What patients are considered high risk for breast cancer?

> 1 first line relative with unilateral breast ca

1 first line relative with bilateral breast ca

1 male relative with breast ca

1 relative with breast or ovarian ca

Previous biopsy showing
* CIS
* Proliferative disease with atypia
* complex fibroadenoma

4

How is breast cancer diagnosed?

Triple Test!!

1. Clinically
* History - Risk factors
* Exam - Lump/mass and LN
* Metastases

2. Mammogram
* 2 views - CC and MLO
* Suspicious lesion

3. FNA and Cytology
* ER/PR status
* Pathological type
* Inconclusive > Core biopsy

5

What is the importance of ER/PR status of a breast carcinoma

ER/PR (+) must NOT get hormone Replacement therapy because it feeds the tumour

6

What are the features of a suspicious lesion on mammogram?

Hyperdense

Spiculated

Pleomorphic microcalcifications

7

What are the most common pathological types of breast cancer?

Infiltrating ductal (75%)

Infiltrating lobular (10%)

8

What are the management guidelines for a Stage I-II breast cancer?

Breast conservtaion therapy with adjuvant radiotherapy

Systemic therapy depending on prognostic factors of the tumor

9

What are the indications for Neo-adjuvant chemotherapy in breast cancer?

All locally advanced disease - Stage IIb; IIIa and IIIb

>4cm mass

To downstage a tumor

If increased risk of micrometastases

To decrease tumour size

HER (+)/(-)

Triple negative - ER/PR/HER (-)

10

What are the indications for Adjuvant chemotherapy in breast cancer?

Age <40 years

ER / PR (-)

> 3 LN involvement

High grade tumours

11

What are the indications for hormone therapy in breast cancer?

ER (+)

Soft tissue metastases

Bone metastases

Pleural effusion (lung metastases)

Local reccurrance

12

What are the indications for a mastectomy (contraindications for BCT) in breast cancer?

High breast : tumour ratio

Previous irradiation to the breast

Multifocal/multicentric tumour

Wide spread microcalcifications on mammography

Tumor > 4cm

BRCA (+)

Patient preference

Collagen vascular disease - coz' radiotherapy C/I
* SLE
* Scleroderma

2 Recurrence of carcinoma

Males

Poor socio-economic circumstances

Pregnancy / Lactation

13

What hormone therapy would you use in a post-menapausal woman with breast cancer?

Tomoxifen
* Inhibits oestrodiol binding
* Especially effective in ER/PR (+) patients

Anastrozole (Arimidex)
* Aromatase inhibitor - inhibits the conversion of androgens to oestrogen

14

What are the side-effects of tomoxifen?

Menopausal symptoms:
* Hot flushes
* Mood changes
* Altered menses / amenorrhoea
* Dry vagina
* Thrush

Thromboembolism
* Stroke
* DVT

Fatty liver changes

Increased risk of endometrial cancer

Vaginal atrophy and bleeding

15

What are the side-effects of Arimidex?

MSK pain

Bone pain

16

What hormone therapy would you use in a pre-menapausal woman with breast cancer?

Ovarian ablation
* Surgical
* GnRH antagonist - Temporary, better for younger patients

Tomoxifen

17

What receives biological therapy in breast cancer and biologic would they receive?

HER-2 (+) patient

Herceptin - monoclonal antibody against HER-2

18

Discuss regional therapy in breast cancer

Palpable Axillary LN
* Axillary dissection via Modified radical mastectomy

Impalpable Axillary LN
* Sentinal LN biopsy

19

Discuss BRCA

Autosomal dominant inheritance

Associated with breast, ovarian, fallopian tube, colon and prostate carcinoma

20

What stage breast cancers would you do a CT scan and bone scan for?

Stage IIb and up

To look for Metastases

21

What are the histological indications for axillary dissection in breast cancer?

Large tumour

Soft tissue invasion

3 or more LN had tumour in it

Extranodal extension of disease

Micrometastases

22

What special investigations would you do in a patient with thyroid pathology and why?

Serum TSH
* Raised in hypothyroidism
* Decreased in hyperthyroidism and euthyroidism

Total T4, free T4 and free T3
* Function of the thyroid

Serum Calcitonin
* Increased in MEN 2 syndrome

Thyroid Antibodies
* Increased in autoimmune thyroiditis

23

Discuss the use of thyroid function tests (TFT)

Elevated TSH and low FT4 = Primary hypothyroidism due to disease in the thyroid gland

Low TSH and low FT4 = Hypothyroidism due to a problem involving the pituitary gland

Low TSH with an elevated FT4 and FT3 = Hyperthyroidism.

24

Discuss Radioactive Iodine (RAI) Uptake testing

Provides a function-anatomical correlation of thyroid lesion

Provides information on risk of malignancy

Cold nodule = High risk of malignancy (20%)

Hot nodule = Lower risk of malignancy (5%)
* Hot nodule + hyperthyroidism = benign

25

What imaging would you do in a patient with thyroid pathology and why?

RAI uptake
* Provides information of risk of malignancy

FNA
* Diagnoses/excludes malignancy

Ultrasound
* Evaluation of thyroid nodules for suspicious signs of malignancy

CT scan
* Metastases

26

What are the suspicous signs of thyroid cancer on ultrasound?

Calcification

Increased vascularity

Irregular borders

Absent halo sign

27

What is the most common thyroid malignancy?

Papillary cell adenocarcinoma

28

What is the origin of a Papillary cell adenocarcinoma of the thyroid?

Arises from follicular epithelial cells

29

What are the risk factors for a Papillary cell adenocarcinoma of the thyroid?

Genetic mutation of BRAF gene

Previous irradiation

Family history of thyroid cancer

Familial syndromes:
* Familial papillary carcinoma
* Familial non-medullary thyroid carcinoma
* Familial adenomatous polyposis coli (FAP)
* Gardner syndrome (Familial colorectal polyposis)
* Turcot syndorme (multiple adenomatous polyps in the colon)

30

What is the clinical presentation of a Papillary cell adenocarcinoma of the thyroid?

Most common (80%)
2:1 female:male ratio
20-30 years

Solitary nodule
* Firm on palpation
* Solid on ultrasound
* Cold on RAI

Dysphagia (invasive)

Dyspnoea (invasive)

Dysphonia (invasive)

Palpable LN

31

What is the route of spread of a Papillary cell adenocarcinoma of the thyroid?

Lymphatic

32

Where does a a Papillary cell adenocarcinoma of the thyroid metastasize to?

Lungs

Bone

33

What investigations would you do for a papillary cell adenocarcinoma of the thyroid??

Thyroid function tests
* Increased TSH
* Normal FT3 and FT4

Ultrasound
* Look for suspicious signs
* Solid

FNA and cytology
* Papillary projections of columnar epithelium
* Psammoma bodies (60%)

RAI
* Cold

34

What is the management of a Papillary cell adenocarcinoma of the thyroid?

Surgical
<1 cm - Lobectomy/Isthmustectomy (Younger patients)
>1 cm - Total thyroidectomy with central node dissection

Adjuvant
* Thyroid hormone suppression and radioiodine therapy
* External beam radiotherapy for >45 years and had locally invasive disease.

Post-Total thyroidectomy
Life-long thyroid hormone replacement therapy

35

What are the indications for a Total thyroidectomy?

(Also contraindications to RAI)

Large/Multinodular goitre with poor RAI uptake

Compression symptoms

Suspicious malignant nodule/ confirmed thyroid cancer

Pregnancy/children

Patients who wish to fall pregnant

Amioderone induced hyperthyroidism

Adverse effects of antithryoids

Unable to follow long term follow-up

36

What are the complications of thyroidectomy?

Thyroid storm

Neck haematoma

Recurrent laryngeal nerve injury

Injury to the external branch of the superior laryngeal nerve

Injury to the oesophagus

Injury to to the great vessels/cervical sympathetic trunk

Hypoparathyroidism

37

Provide a DDx for a solitary nodule of the thyroid

Cyst

Colloid nodule

Papillary cell adenocarcinoma

Follicular cell adenocarcinoma

38

What is the origin of a medullary carcinoma of the thyroid?

Arises from the parafollicular cells
*Secretes calcitonin and CEA

39

What are the risk factors for medullary carcinoma of the thyroid?

RET oncogene on chromosome 10

MEN syndrome 2A and 2B

40

What is the presentation of medullary carcinoma of the thyroid?

Sporadic type
* Unilateral, solid, hard, nodular neck mass

Familial type
* Bilateral/multicentric hard, nodular neck mass

41

What is the route of spread for medullary carcinoma of the thyroid?

Haematogenous
* LN
* Bone
* Lung

42

Where does a medullary carcinoma of the thyroid metastasize to?

Early
* Adjacent muscle
* Trachea
* Local and mediastinal LN

Late
* Bones
* Lungs
* Liver
* Adrenals

43

How would you diagnose a medullary carcinoma of the thyroid?

Bloods
* Raised Calcitonin
* Raised CEA

FNA

RAI
* Cold

44

How would you manage a medullary carcinoma of the thyroid?

(If present, phaeochromocytoma should be managed first)

Total thyroidectomy + modified neck dissection if cervical LN affect

45

Define MEN syndrome

It is a group of autosomal dominant disorders characterized by the growth of benign and malignant endocrine tumours

46

What are the clinical features of MEN-1 syndrome?

Hyperparathyroidism

Pancreatic tumours

Pituitary adenomas

Adrenal adenoms

Carcinoid tumours

47

What is the management of MEN-1 syndrome?

Hyperparathyroidism
* Medical - Calcimimetics
* Surgical - Parathyroidectomy with thymectomy

Gastrinomas
* Medical - PPI's (omeprazole)

48

What are the clinical features of MEN-2A syndrome?

Medullary carcinoma of the thyroid (80-100%)

Phaeochromocytoma (40%)
* HPT
* Headaches
* Palpitations
* Diaphoresis

49

How would you diagnose MEN-2A syndrome?

Genetic testing - RET mutation

Serum calcitonin after 3 days of omeprazole

50

What is the management of MEN-2A/2B syndrome?

Medullary carcinoma of the thyroid
* Prophylactic thyroidectomy in kids with RET mutation

Phaeochromocytoma
* alpha-blockers + beta-blockers
* Unilateral/bilateral adrenalectomy

51

What are the clinical features of MEN-2B syndrome?

Medullary carcinoma of the thyroid

Mucosal neuromas
* Bumpy, enlarged lips and tongue

Phaeochromocytoma
* HPT
* Headaches
* Palpitations
* Diaphoresis

Skeletal abnormalities

Marfanoid habitus

52

What is the most common salivary gland neoplasm?

Parotid tumours - Benign pleomorphic adenoma

53

What is the clinical presentation of a malignant parotid mass?

Rapid growth

Pain

Paraesthesia

Facial nerve (CN VII) weakness/palsy

Skin invasion and fixation to mastoid tip

54

How would you diagnose a salivary gland tumour?

FNA

Surgical excision
* Provides a definite histopathological diagnosis

MRI
* Better soft-tissue visualization
* Can see soft tissue extension and involvement of adjacent structures

55

How would you manage a benign pleomorphic adenoma of the parotid gland?

Superficial parotidectomy with preservation of the facial nerve

56

What are the indications for adjuvant radiation therapy in salivary gland tumours?

Extraglandular disease

Perineural invasion

Direct invasion of regional structures

Regional metastases

High-grade histology