Week 7 - Cancer & Head and Neck Flashcards
Illustrate with 5 examples, how benign neoplasms cause death.
Benign neoplasms, by definition, do not invade surrounding tissues or metastasize to distant sites. They typically grow slowly and have a localized nature. In general, benign tumors do not cause death unless they are located in critical or vital organs and exert pressure or disrupt their normal functions.
What are 5 ways in which benign tumours can cause complications?
While benign tumors are non-cancerous and do not metastasize, they can still cause complications depending on their location, size, and effect on surrounding tissues.
Define:
- Neoplasia
- Metaplasia
- Dysplasia
- Sarcoma
- Anaplasia
List 5 Types of Sarcomas?
Discuss the management of a patient presenting with a cancer of unknown primary.
- 7 Steps?
Cancer of unknown primary (CUP), also known as occult primary cancer, refers to the situation where metastatic cancer is diagnosed, but the primary site of the cancer cannot be identified despite thorough evaluation. Managing a patient with CUP involves a comprehensive diagnostic workup, treatment planning, and supportive care. The management approach may vary depending on factors such as the patient’s overall health, extent of metastasis, histological features of the cancer, and available treatment options. Here is a general outline of the management of a patient with CUP:
What is the importance of staging cancers?
(5 reasons)
Staging cancer is a critical process in the evaluation and management of cancer patients. It involves determining the extent of cancer spread within the body, including the primary tumor size, involvement of nearby lymph nodes, and the presence of distant metastases.
Compare and contrast patients presenting with left and right-sided colonic neoplasms.
The cecum, appendix, ascending colon, hepatic flexure, and proximal two thirds of the transverse colon have originated from the midgut, whereas distal one third of the transverse colon, splenic flexure, sigmoid colon, descending colon and rectum have originated from the hindgut.
Describe the anatomy of the inguinal lymph nodes.
- Superficial & Deep groups?
- Locations?
- Structure they drain?
- Lymph nodes they drain into?
List 6 Causes of Inguinal Lymphadenopathy with examples for each?
Outline your management of a 45 year old man presenting with an enlarged left groin node. (5 Steps)
Outline your management of a patient found to have an incidental adrenal mass on CT scanning.
An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, serendipitously discovered by radiologic examination.
Differential Diagnoses
- Benign, non-functioning adrenal adenomas account for about 80% of adrenal incidentalomas. Of the tumours that are functional:
- 5% are pheochromocytomas
- 5% cortisol-producing
- 1% aldosterone-producing.
Adenomas that produce sex hormones are very rare. Malignant tumours, such as primary adrenocortical carcinomas, account for <5% and metastases for <3% of adrenal incidentalomas.
Tumours that commonly metastasise to the adrenal gland include: Lung, Colon,. Breast, Renal, Stomach, Melanoma, Lymphoma.
Outline your management of a patient found to have an incidental adrenal mass on CT scanning - 6 Steps?
How would you investigate a patient found to have an incidental 2cm mass in their liver on an USS?
- 6 Steps?
When an incidental 2cm liver mass is found on ultrasound, further investigation is necessary to determine the nature of the mass.
What are the possible causes of a tender right iliac fossa mass in a 20-year-old man? (6)
If the patient were 78, how would your differential alter? (5)
What are 9 differential diagnoses of a non-tender mass in the left iliac fossa in an 80-year-old man?
How would you manage a patient presenting with a painless 8 cm mass in the lateral compartment of the thigh?
- 5 Red Flags?
- History?
- Examination?
- Investigations?
- 6 Step approach?
Red flags
1. Greater than 5 cm in diameter
2. Deep to fascia (fixed) and any size
3. Growing rapidly
4. Painful
5. Recurring after a previous sarcoma excision
List and describe 5 features of lumps found on routine examination of the patient and 5 management options.
When a lump is found on routine examination of a patient, it is important to assess its features and characteristics to determine the appropriate management.
Discuss your management of 20-year-old woman presenting to outpatients with a lump in the neck, which, on examination is in the left lobe of the thyroid.
- History?
- Exam?
- Investigations?
- Tx?
What are thyroid nodules? What are they most likely to be? How do we investigate them?
What are 4 causes of benign thyroid nodules?
- 4 types of thyroid adenomas?
3 Types of Malignant thyroid nodules?
Benign Thyroid Nodules (∼ 95% of cases)
1) Thyroid adenomas
- Follicular adenoma (most common)
- Hürthle cell adenoma
- Toxic adenoma
- Papillary adenoma (least common)
2) Thyroid cysts
3) Dominant nodules of multinodular goiters
4) Hashimoto thyroiditis
Malignant Thyroid Nodules (∼ 5% of cases)
1. Thyroid carcinoma
2. Thyroid lymphoma
3. Metastatic cancer from breast/renal carcinoma (rare)
What are the red flags for thyroid cancer?
- 4 Patient characteristics?
- 2 Symptoms?
- 3 Palpatory findings?
In addition to red flags for thyroid cancer, a solid nodule on thyroid ultrasound or a cold nodule on thyroid scintigraphy should raise suspicion for thyroid cancer.
Describe an approach to the diagnosis of a thyroid nodule?
- All thyroid nodules (including thyroid incidentalomas) should be evaluated for malignancy.
- Initial tests in all patients: TSH levels and thyroid ultrasound.
- Subsequent tests
1. Thyroid scintigraphy for patients with low TSH
2. Cytology if ultrasound examination shows indications for FNAC in thyroid nodules - Additional tests
3. Diagnostic workup of hyperthyroidism or hypothyroidism (e.g., fT4, total T3, thyroid antibodies)
4. Thyroid cancer tumor markers (e.g., serum calcitonin for suspected medullary carcinoma)
Which 2 tests should always be involved in the initial evaluation of a thyroid nodule?
Initial evaluation
1) Serum TSH: may be normal, elevated, or low
- Elevated TSH: associated with a higher risk of malignancy in thyroid nodules
- Low TSH: indication for thyroid scintigraphy
2) Thyroid ultrasound:
- Indicated in patients with palpable nodules or if there is clinical suspicion of malignancy
- Assess each nodule individually for risk features.
- Solid, hypoechoic nodules with irregular margins, microcalcifications, taller-than-wide shape, extrathyroidal growth, and/or cervical lymphadenopathy should raise suspicion for malignancy and require further evaluation with FNAC.
What is Thyroid Scintigraphy?
- Indication?
- Contraindications?
- Findings and interpretation?
Thyroid scintigraphy = A nuclear medicine test in which a radiotracer (usually radioactive iodine) is administered to a patient. The thyroid gland absorbs the tracer, and the radiation is measured with an imaging device to create pictures of the gland that provide information about its function. Often combined with radioactive iodine uptake measurement.
What are 4 Indications for FNAC of thyroid nodules?
- Procedure?
- How are the findings categorized?
If thyroid scintigraphy is performed, sonographic features of thyroid nodules should be used to determine which cold nodules require FNAC. Cold nodules with a benign appearance on thyroid ultrasound do not routinely require FNAC.
List three specific complications of a total thyroidectomy and outline your management of these.
What questions need to be asked during history taking of a patient presenting with a thyroid nodule?
List 8 differentials for a thyroid nodule?
- Non‑toxic goitre
- Hashimoto’s thyroiditis
- Graves’ disease
- Iodine deficiency
- Colloid cyst
- Follicular adenoma
- Cancer
- Non‑thyroid pathology
Outline the diagnostic imaging pathway for a thyroid nodule.
List the lymph nodes of the head and neck.
Deep Lymph Nodes
1. Submental
2. Submandibular (Submaxillary)
Anterior Cervical Lymph Nodes (Deep)
3. Prelaryngeal
4. Thyroid
5. Pretracheal
6. Paratracheal
Deep Cervical Lymph Nodes
7. Lateral jugular
8. Anterior jugular
9. Jugulodigastric
Inferior Deep Cervical Lymph Nodes
10. Juguloomohyoid
11. Supraclavicular (scalene)
Where are the jugulodigastric lymph nodes and what structures do they drain?
- The jugulodigastric lymph nodes are found in the proximity of where the posterior belly of the digastric muscle crosses the internal jugular vein.
- Nodes are typically around 15 mm in length in adults, and decrease in size during old age.
- They tend to be some of the largest lymph nodes in the cervical chain due to their significant lymphatic drainage.
- The jugulodigastric lymph nodes are the first to receive lymphatic drainage from face, mouth, pharynx, and tonsils.
Outline your management of a 34-year-old woman presenting with an enlarged non-tender jugulodigastric lymph node.
List the possible causes of peripheral lymphadenopathy?
Describe 4 pathological processes that can cause lymph node enlargement?
History taking and Physical examination of a patient with lymphadenopathy?
- Soft, mobile, and tender lymph nodes are likely benign. Hard, nonmobile, nontender lymph nodes should raise concern for malignancy. Firm, nontender lymph nodes in patients with sarcoidosis or tuberculosis are exceptions.
- A palpable, firm lymph node in the left supraclavicular area is called a Virchow node and is classically associated with gastric carcinoma.
Generalized lymphadenopathy is defined as the enlargement of more than two noncontiguous lymph node groups.
Which diagnostics tests would you order for:
- Acute, painful lymphadenopathy?
- Chronic, localised lymphadenopathy?
- Painless, slowly progressing lymphadenopathy?
When should fasting commence prior to surgery?
Which antibiotics are first line for Perioperative antibiotic prophylaxis?
What is the treatment for tetanus?
Tetanus immunoglobulin:
- for intramuscular use to manage tetanus-prone wounds
- for intravenous use to treat clinical tetanus
What are 4 indications for the tetanus vaccine?
Tetanus-containing vaccine is recommended for:
1. routine vaccination in infants, children and adolescents
2. routine booster vaccination in adults, including travellers to countries where health services are difficult to access
3. post-exposure prophylaxis in people with a tetanus-prone wound
4. vaccination of people who have missed doses of tetanus-containing vaccine
- Boosters with Td or Tdap are recommended every 10 years for all adolescents and adults who have completed the primary Tdap and DTaP series.
- One dose of Tdap is recommended for each pregnancy (preferably between 27–36 weeks’ gestation).
Discuss the Requirement for tetanus prophylaxis?
- Give tetanus immunoglobulin to people with a humoral immune deficiency and people with HIV (regardless of CD4+ count) if they have a tetanus-prone injury. This is regardless of the time since their last dose of tetanus-containing vaccine.
- People who have no documented history of a complete primary vaccination course (3 doses) with a tetanus-containing vaccine should receive all missing doses and must receive tetanus immunoglobulin for tetanus-prone wounds.
Discuss the Benefit/risk of PPI use perioperatively?
Proton pump inhibitors (PPIs) are occasionally used to reduce pH and the amount of gastric acid before general anesthesia, but they may also have an anti-nausea effect.
Discuss the key points regarding PPI mitigation policies perioperatively? (6)
What is the scope of endocrine surgery?
- Outline the steps involved in the physical examination of the thyroid?
- Thyroid Gland
- Parathyroid Gland
- Pituitary Gland
- Adrenal Glands
- Other surgical endocrine syndromes
What are 5 Causes of Enlargement (Goitre) of Thyroid?
- Features of Thyroid Disease: Structure? Function? Pathology?
- Non toxic goitre (multinodular)
- Thyrotoxic goitre
- Thyroiditis
- Solitary Thyroid nodules
- Other forms of neoplasia
Non-Toxic Nodular Goitre
- Aetiology?
- Prevention?
- Presentation? (4)
- 4 Investigations?
- Management? (2)
Presentation
1. Asymptomatic (majority)
2. Dysphagia
3. Stridor
4. Acute englargement = pain & compression
Thyroiditis
- 3 Aetiologies?
- 4 Features of Hashimoto’s?
- 2 Investigations for Hashimoto’s?
- Management of Hashimoto’s?
What are the differentials for a solitary thyroid nodule?
- How are they investigated?
Hyperthyroidism
- 3 Possible Causes?
- Pathophysiology of Primary Thyrotoxicosis (Grave’s Disease)?
- Primary Thyrotoxicosis (Grave’s Disease)
- Toxic Multi Nodular Goitre
- Toxic Adenoma
Graves Disease
- 7 Clinical Features & 7 Sympathetic effects?
- 6 Other features?
- Management? (3)
Types of Thyroid Cancer? Malignant tumours of the Thyroid?
Papillary Carcinoma of the Thyroid
- 3 Clinical Features?
- Management?
Follicular Carcinoma of the Thyroid
- 4 Clinical Features?
- Management?
Anaplastic Carcinoma of the Thyroid
- Clinical Features?
- Management?
Medullary Carcinoma of the Thyroid
- 4 Clinical Features?
- Management?
Thyroid Lymphoma
- Clinical Features?
- Management?
List 3 Complications of Thyroidectomy and 2 Management strategies post-op?
- 3 Hormones involved in the regulation of calcium metabolism?
- 5 Causes of Hypercalcaemia?
Calcium Metabolism Regulation
1. PTH
2. Vitamin D
3. Calcitonin
8 Causes of Hypocalcaemia?
Calcium is bound to proteins (eg. Albumin) so if liver cirrhosis = reduced synthesis & acute pancreatitis (albumin with calcium bound to it leaks into third space)
Primary Hyperparathyroidism
- Pathology? (3)
- Clinical features?
- Hypercalcaemia crisis?
Primary Hyperparathyroidism - Pathology
1. Benign Adenoma (5-10% Double)
2. 10% - Hyperplasia
3. 1% - Carcinoma
Hypercalcaemia Crisis - Suspect oncology & Bony Mets!
- S.Calcium >3.5mmol/L
- Nausea, vomiting, dehydration
- Treatment: IV Fluids ++ & Diphosphonates
Primary Hyperparathyroidism
- Diagnosis? (6)
- Management?
Causes of Secondary & Tertiary Hyperparathyroidism?
Hypoparathyroidism
- Causes?
- Clinical features?
- Treatment?
Cushing Syndrome
- 5 Causes?
- Clinical features?
- Differentiation/Diagnosis?
- Management?
What is Conn’s Syndrome?
- Diagnosis? (4)
Phaeochromocytoma
- Rule of 9s?
- Clinical Features?
Sympotoms explained by increased catecholamines
Phaeochromocytoma
- 5 Investigations?
- Management?
Non-Endocrine Sympathetic Nerve Tumours
- 2 Examples?
- Treatment?
Adrenal ‘Incidentaloma’
- What are they?
- Management?
3 MEN I Tumours?
6 MEN II Tumours?
Carcinoid Tumours
- Sites?
- Pathophysiology?
Carcinoid Syndrome
- 5 Signs & Symptoms?
- Diagnosis?
- Treatment?
