20- Breast & Endocraniology Explains Flashcards
1
Q
What is the indication for endocrine therapy in breast cancer treatment?
A
Endocrine therapy is indicated for oestrogen receptor positive tumours, downstaging primary lesions, and as definitive treatment in old or infirm patients.
2
Q
When is irradiation and wide local excision used in breast cancer treatment?
A
Irradiation and wide local excision are used in cases of large lesions, high grade or marked vascular invasion following mastectomy.
3
Q
When is chemotherapy used in breast cancer treatment?
A
Chemotherapy is used to downstage advanced lesions to facilitate breast-conserving surgery, and for patients with grade 3 lesions or axillary nodal disease.
4
Q
What are the endocrine agents used in breast cancer treatment?
A
Tamoxifen is commonly used as a partial oestrogen receptor agonist. Aromatase inhibitors are the preferred agents in postmenopausal women. Perimenopausal women start on tamoxifen and may switch to aromatase inhibitors after 3 years.
5
Q
What is the most commonly used chemotherapy regime in breast cancer treatment?
A
The FEC regime (Fluorouracil, epirubicin, and cyclophosphamide) is the most commonly used chemotherapy regime. Taxanes are commonly used in high-risk patients.
6
Q
What limits the use of anthracycline class drugs in chemotherapy?
A
Anthracycline class drugs have marked cardiotoxicity, which can limit their use. This property is shared with trastuzumab.
7
Q
What is gynaecomastia?
A
Gynaecomastia is the presence of abnormal breast tissue in males, typically caused by an increased oestrogen to androgen ratio.
8
Q
What syndromes with androgen deficiency can cause gynaecomastia?
A
Kallman’s syndrome and Klinefelter’s syndrome are examples of syndromes with androgen deficiency that can cause gynaecomastia.
9
Q
What are some medical conditions that can cause gynaecomastia?
A
Medical conditions such as testicular failure (e.g., mumps), liver disease, testicular cancer (e.g., Seminoma secreting HCG), ectopic tumour secretion, hyperthyroidism, and undergoing haemodialysis can cause gynaecomastia.
9
Q
What are some very rare drug causes of gynaecomastia?
A
Very rare drug causes of gynaecomastia include tricyclic antidepressants, isoniazid, calcium channel blockers, heroin, busulfan, and methyldopa.
10
Q
Which drugs are commonly associated with gynaecomastia?
A
Common drug causes of gynaecomastia include spironolactone (most common), cimetidine, digoxin, cannabis, finasteride, oestrogens, and anabolic steroids.
11
Q
What are the treatment options for gynaecomastia?
A
The treatment options for gynaecomastia include identifying and managing any underlying causes and considering liposuction for the best cosmetic outcome.
12
Q
What is a fibroadenoma?
A
A fibroadenoma is a type of breast lesion that commonly occurs in young females under the age of 25. It is characterized by the formation of dense stroma within the breast tissue, resulting in the development of palpable lumps.
13
Q
What percentage of palpable breast lesions do fibroadenomas account for?
A
Fibroadenomas account for approximately 13% of all palpable breast lesions. However, in women aged 18-25, they constitute up to 60% of all palpable breast lesions.
14
Q
What are the different classifications of fibroadenomas?
A
Fibroadenomas are classified as juvenile, common, and giant. Juvenile fibroadenomas occur in early adolescence, while giant fibroadenomas are characterized by a size greater than 4cm.
15
Q
What is the recommended approach for small fibroadenomas in young females?
A
For young females with small fibroadenomas (less than 3cm on imaging), a policy of watchful waiting without biopsy may be adopted.
16
Q
When is a core biopsy recommended for fibroadenomas?
A
A core biopsy is recommended for fibroadenomas that exceed a size of 4cm to exclude the possibility of a phyllodes tumor.
17
Q
What is the natural history of fibroadenomas?
A
In the natural history of fibroadenomas, approximately 10% will increase in size, 30% will regress, and the remaining will stay the same. However, during pregnancy and lactation, fibroadenomas may increase in size substantially and sequester milk.
18
Q
What are the treatment options for fibroadenomas?
A
Some women may choose to have their fibroadenomas excised. They can usually be removed through a circumareolar incision. Smaller lesions may be removed using a mammotome.
19
Q
What are breast cysts?
A
Breast cysts are fluid-filled sacs that make up approximately 15% of all breast lumps. They are most common in perimenopausal females and are caused by distended and involuted lobules.
20
Q
How can breast cysts be identified on clinical examination?
A
Breast cysts can be readily apparent on clinical examination as soft, fluctuant swellings. It’s important to exclude the presence of an underlying mass lesion.
21
Q
What imaging findings are associated with breast cysts?
A
On mammography, breast cysts usually show a “halo appearance.” Ultrasound can confirm the fluid-filled nature of the cyst.
22
Q
What is the recommended approach for symptomatic breast cysts?
A
Symptomatic breast cysts may be aspirated, and following aspiration, the breast should be re-examined to ensure that the lump has disappeared.
23
Q
What is duct ectasia?
A
Duct ectasia is a condition that occurs as women progress through menopause. It is characterized by the shortening and dilation of breast ducts. Some women may experience a cheese-like nipple discharge and slit-like retraction of the nipple. No specific treatment is required for duct ectasia.
24
What imaging modalities are typically used for breast imaging?
Breast imaging is typically performed using a combination of ultrasound (USS) and mammography, especially in women presenting with a palpable lump.
25
Why may mammography be less informative in younger patients?
In younger patients, the denser breast tissue encountered in this age group may make mammography less informative.
26
What imaging modality is recommended for women with breast implants and a palpable lump?
For women with breast implants and a palpable lump, the imaging modality of choice remains the same, which is a combination of USS and mammography. However, specialized imaging techniques may be needed to obtain optimal mammographic views.
27
When is MRI scanning the preferred imaging modality for breast concerns?
If there are specific concerns about a breast implant, rather than a lump, MRI scanning is the preferred imaging modality. It is also beneficial in screening younger patients with a family history and in patients with lobular cancers who are being considered for breast-conserving surgery.
28
What are the features of fibroadenomas?
Fibroadenomas are mobile, firm breast lumps that develop from a whole lobule. They account for 12% of all breast masses and have no increase in the risk of malignancy. Over a 2-year period, up to 30% of fibroadenomas will get smaller. If a fibroadenoma is larger than 3cm, surgical excision is usually performed. Phyllodes tumors should be widely excised, and mastectomy may be necessary for large lesions.
29
What are the characteristics of breast cysts?
Breast cysts are present in 7% of all Western females and usually manifest as a smooth, discrete lump that may be fluctuant. There is a small increased risk of breast cancer, especially in younger individuals. Cysts should be aspirated, and those that are blood-stained or persistently refill should be biopsied or excised.
30
What are sclerosing adenosis, radial scars, and complex sclerosing lesions?
Sclerosing adenosis, radial scars, and complex sclerosing lesions typically present as breast lumps or breast pain. They cause mammographic changes that may mimic carcinoma. These lesions distort the distal lobular unit without hyperplasia, although complex lesions may show hyperplasia. They are considered disorders of involution and do not increase the risk of malignancy. Biopsy is recommended, but excision is not mandatory for these lesions.
31
What is epithelial hyperplasia?
Epithelial hyperplasia has a variable clinical presentation ranging from generalised lumpiness to discrete lumps. It is characterized by increased cellularity of the terminal lobular unit, and atypical features may be present. Individuals with atypical features and a family history of breast cancer have a significantly increased risk of malignancy. Treatment depends on the presence of atypical features, with conservative management or surgical resection being options. Close monitoring is also recommended for those with atypical features.
32
What is fat necrosis?
Fat necrosis is a condition that usually has a traumatic cause in up to 40% of cases. Its physical features often mimic carcinoma, and the mass may initially increase in size. Imaging and core biopsy are used for diagnosis.
33
What are duct papillomas?
Duct papillomas commonly present with nipple discharge, while large papillomas may present as a mass. The discharge usually originates from a single duct. Duct papillomas do not increase the risk of malignancy. Treatment typically involves microdochectomy.
34
Why is accurate staging of the axilla important in breast cancer management?
Accurate staging of the axilla is essential in breast cancer management because involvement of the axillary nodes has an adverse effect on prognosis. The 10-year survival rate is reduced from 75% to 25% in cases where the axillary nodes are involved.
35
What is the worst prognosis regarding axillary node involvement?
Involvement of level 3 nodes carries the worst prognosis in terms of breast cancer.
36
What are the historical approaches to axilla management in breast cancer?
Historically, management of the axilla ranged from limited level 1 axillary node excision to full level 3 axillary nodal clearances.
37
What are the targeted operations for axillary node management?
To minimize the morbidity of axillary node clearance, targeted operations have been developed, including axillary nodal sampling and sentinel lymph node biopsy.
38
What is the debate regarding axillary nodal micrometastasis?
There is debate regarding the presence of axillary nodal micrometastasis and its impact on survival. Some studies suggest that it confers an increased risk of locoregional recurrence and a reduction in disease-free survival, while others show no overall impact. It is important to distinguish between micrometastasis and isolated tumor cells, as the latter do not have an adverse impact on prognosis.
39
What was the finding of the ASCOG Z0011 trial?
The ASCOG Z0011 trial addressed the need for definitive treatment of the axilla in women with positive sentinel nodes. The trial found no survival benefit in routinely undertaking axillary node clearance when axillary nodal disease was limited in its extent.
40
What is the recommended treatment for individuals with overt evidence of axillary nodal involvement?
Individuals with overt evidence of axillary nodal involvement, either through positive sentinel lymph node biopsy or preoperative ultrasound and fine-needle aspiration, should still receive complete axillary treatment, either through clearance or radiotherapy.
41
What are the common treatments for breast cancer?
The common treatments for breast cancer include surgery, chemotherapy, hormonal therapy, and radiotherapy.
42
What is the purpose of chemotherapy in breast cancer management?
Chemotherapy may be used to downstage tumors and allow for breast-conserving surgery.
43
What is the role of hormonal therapy in breast cancer management?
Hormonal therapy can also be used to downstage tumors and enable breast-conserving surgery.
44
When is radiotherapy given to patients with breast cancer?
Radiotherapy is given to most patients who have undergone breast-conserving surgery. However, some older patients receiving hormone treatment and who have small, low-grade tumors may safely avoid radiotherapy.
45
What is therapeutic mammoplasty?
Therapeutic mammoplasty is an option for some patients and involves symmetrizing surgery in most cases.
46
What options are available for patients who have undergone mastectomy?
Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or at a later stage.
47
How is axillary disease managed in breast cancer patients?
As a minimum, all patients with invasive breast cancer should have their axilla staged. This can be done using sentinel lymph node biopsy for those without overt evidence of axillary nodal involvement. Patients with a positive sentinel lymph node biopsy or evidence of axillary nodal metastasis should undergo axillary node clearance or axillary irradiation.
47
What are the surgical options for breast cancer?
The surgical options for breast cancer include mastectomy and wide local excision. The choice between the two depends on factors such as tumor characteristics, breast size, and patient preference.
48
What are the risks associated with axillary node clearance?
Axillary node clearance is associated with the development of lymphedema, an increased risk of cellulitis, and frozen shoulder.
49
How are thyroid function test results interpreted for thyrotoxicosis (e.g. Graves' disease)?
In cases of thyrotoxicosis, the TSH levels are low while the free T4 levels are high. It is important to note that in T3 thyrotoxicosis, the free T4 levels may still be within the normal range.
50
What are the thyroid function test results for primary hypothyroidism?
Primary hypothyroidism is characterized by high TSH levels and low free T4 levels.
51
What are the thyroid function test results for secondary hypothyroidism?
Secondary hypothyroidism is characterized by low TSH levels and low free T4 levels. In such cases, replacement steroid therapy is required before initiating thyroxine treatment.
52
What are the thyroid function test results for sick euthyroid syndrome?
In sick euthyroid syndrome (non-thyroidal illness), both TSH and free T4 levels are low. This condition is commonly observed in hospitalized patients.
53
What are the thyroid function test results for poor compliance with thyroxine medication?
In cases of poor compliance with thyroxine medication, TSH levels are high, while free T4 levels are either normal or high.
54
What is the alternative term for sick euthyroid syndrome?
Sick euthyroid syndrome is now referred to as non-thyroidal illness.
Yes, TSH levels may be normal in some cases of sick euthyroid syndrome.
55
What are the thyroid function test results for steroid therapy?
Steroid therapy can result in high TSH levels and normal or high free T4 levels.
56
What is the most common subtype of thyroid malignancy?
The most common subtype of thyroid malignancy is papillary carcinoma.
57
How is papillary carcinoma accurately diagnosed?
Papillary carcinoma is accurately diagnosed through fine needle aspiration cytology.
58
How does papillary carcinoma typically metastasize?
Papillary carcinoma typically metastasizes via the lymphatics, which is why laterally located apparently ectopic thyroid tissue is usually a metastasis from a well-differentiated papillary carcinoma.
59
What histological features may be present in papillary carcinoma?
Histologically, papillary carcinoma may demonstrate psammoma bodies (areas of calcification) and "orphan Annie" nuclei.
60
What are the characteristics of follicular carcinoma?
Follicular carcinoma is less common than papillary lesions. While they may present as a discrete nodule, microscopic evaluation reveals invasion despite appearing well encapsulated macroscopically. Lymph node metastases are uncommon, and these tumors tend to spread hematogenously, resulting in a higher mortality rate.
61
How is follicular carcinoma diagnosed?
Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology. Therefore, all follicular FNAs (THY 3f) will require at least a hemithyroidectomy.
62
What are the characteristics of anaplastic carcinoma?
Anaplastic carcinoma is less common and tends to occur in elderly females. The disease is usually advanced at presentation, and only palliative decompression and radiotherapy can be offered.
63
What are the characteristics of medullary carcinoma?
Medullary carcinoma is a tumor of the parafollicular cells (C Cells) and has a neural crest origin. Serum calcitonin levels may be elevated, which is useful for monitoring recurrence. It may be familial and occur as part of the MEN-2A disease spectrum. These tumors can spread via lymphatic or hematogenous routes and are not responsive to radioiodine as they are not derived primarily from thyroid cells.
64
How do lymphomas of the thyroid respond to treatment?
Lymphomas of the thyroid respond well to combined chemoradiotherapy. Radical surgery is unnecessary once the disease has been diagnosed on biopsy material, which is obtained through a core biopsy (with care!) rather than fine needle aspiration.
65
What is the recommended management for a large multinodular goiter?
For a large multinodular goiter, surgery is recommended if there are pressure symptoms. The treatment of choice is a total thyroidectomy.
66
What is the management approach for a toxic nodule?
A hemithyroidectomy is the management approach for a toxic nodule.
67
What is the recommended management for a follicular lesion (THY 3f)?
To establish a diagnosis for a follicular lesion (THY 3f), a hemithyroidectomy is recommended.
68
What is the management approach for papillary thyroid cancer?
The management approach for papillary thyroid cancer is a total thyroidectomy and central compartment nodal dissection. An extended lymphadenectomy may be required.
69
What is the management approach for follicular thyroid cancer?
For follicular thyroid cancer, a total thyroidectomy is usually performed, especially if the patient has already undergone a hemithyroidectomy.
70
What is the recommended management for anaplastic thyroid cancer?
Palliative radiotherapy is the recommended management for anaplastic thyroid cancer.
71
What should be considered in the management of lymphoma of the thyroid?
In the management of lymphoma of the thyroid, a core biopsy should be considered.
72
What is the management approach for medullary thyroid cancer?
The management approach for medullary thyroid cancer is a total thyroidectomy. Screening for other MEN (multiple endocrine neoplasia) tumors should also be conducted.
73
What is the recommended management for persistent refilling cysts?
For persistent refilling cysts, injection sclerotherapy is the initial approach. If this fails, surgery may be required.
74
What is the management approach for Graves disease with significant eye signs?
The management approach for Graves disease with significant eye signs is a total thyroidectomy.
75
What are the management options for Graves disease without significant eye signs?
For Graves disease without significant eye signs, the management options include patient choice between radioiodine treatment and surgery.
76
What is the significance of thyroid peroxidase (microsomal) antibodies in blood testing?
Thyroid peroxidase antibodies are found in autoimmune diseases that affect the thyroid, such as Hashimoto's disease (100%) and Graves' disease (70%).
77
Who usually has antibodies to the TSH receptor in their blood?
Individuals with Graves' disease typically have antibodies to the TSH receptor in their blood (95%).
78
What does the presence of calcitonin in blood indicate?
Calcitonin is released from the parafollicular cells and is usually found in patients with medullary carcinoma of the thyroid. Its presence in blood testing can be indicative of this type of thyroid cancer.
79
What is the usefulness of thyroglobulin in clinically distinguishing between different types of thyroid disease?
Thyroglobulin is not useful for clinically distinguishing between different types of thyroid disease. However, it may be used as part of thyroid cancer follow-up.
80
What are the causes of nipple discharge?
The causes of nipple discharge include physiological changes during breastfeeding, galactorrhea (often due to emotional events or certain drugs), hyperprolactinemia (commonly caused by pituitary tumors), mammary duct ectasia (most common in menopausal women), carcinoma (often blood-stained discharge with underlying mass or lymphadenopathy), and intraductal papilloma (more common in younger patients with blood-stained discharge and no palpable lump).
81
What is the commonest cause of galactorrhea?
The commonest cause of galactorrhea may be a response to emotional events. Certain drugs, such as histamine receptor antagonists, are also implicated.
82
What is the most common type of pituitary tumor causing hyperprolactinemia?
The most common type of pituitary tumor causing hyperprolactinemia is microadenomas, which are less than 1cm in diameter. Macroadenomas, which are larger than 1cm in diameter, can cause pressure on the optic chiasm and result in bitemporal hemianopia.
83
What is mammary duct ectasia?
Mammary duct ectasia refers to the dilatation of breast ducts. It is most common in menopausal women and is characterized by thick and green-colored discharge. It is more frequently seen in smokers.
84
What are the characteristics of nipple discharge in carcinoma?
Nipple discharge in carcinoma is often blood-stained. It may be associated with an underlying mass or axillary lymphadenopathy.
85
How does intraductal papilloma typically present?
Intraductal papilloma is more common in younger patients. It may cause blood-stained discharge, but there is usually no palpable lump.
86
What is the recommended assessment for patients with nipple discharge and a mass lesion?
Patients with nipple discharge and a mass lesion should undergo triple assessment, which involves examining the breast and determining the presence of a mass lesion.
87
How are investigations for nipple discharge reported?
Investigations for nipple discharge are reported using a system that denotes the investigation type. For example, a numerical code is used, such as 1 for no abnormality, 2 for abnormality with benign features, 3 for indeterminate probably benign, 4 for indeterminate probably malignant, and 5 for malignant.
88
What is the management approach for non-malignant nipple discharge?
For non-malignant nipple discharge, it is important to exclude endocrine disease. Nipple cytology is unhelpful in this context. Smoking cessation advice is recommended for duct ectasia. In cases of severe symptoms with duct ectasia, total duct excision may be warranted.
89
What are the common features of follicular adenoma?
Follicular adenomas usually present as a solitary thyroid nodule. Malignancy can only be excluded through formal histological assessment.
90
What are the characteristics of papillary carcinoma?
Papillary carcinomas usually contain a mixture of papillary and colloidal filled follicles. Histologically, the tumor has papillary projections and pale empty nuclei. They are seldom encapsulated, and lymph node metastasis is more common than hematogenous metastasis. Papillary carcinomas account for 60% of thyroid cancers.
91
How does follicular carcinoma differ from follicular adenoma?
Follicular carcinomas may appear macroscopically encapsulated, but microscopically, capsular invasion is seen. Without this finding, the lesion is considered a follicular adenoma. Vascular invasion is more predominant in follicular carcinoma, and multifocal disease is rare. Follicular carcinomas account for 20% of all thyroid cancers.
92
What are the main features of anaplastic carcinoma?
Anaplastic carcinomas are most common in elderly females. Local invasion is a common feature. They account for 10% of thyroid cancers. Treatment involves resection when possible, and palliation may be achieved through isthmusectomy and radiotherapy. Chemotherapy is generally ineffective.
93
What are the characteristics of medullary carcinoma?
Medullary carcinomas are tumors of the parafollicular cells (C Cells). These cells are derived from neural crest, not thyroid tissue. Serum calcitonin levels are often elevated. Up to 20% of cases are associated with familial genetic disease. Both lymphatic and hematogenous metastasis are recognized, with nodal disease being associated with a very poor prognosis.
94
What is the most common type of breast cancer?
Invasive ductal carcinomas are the most common type of breast cancer. Some may arise as a result of ductal carcinoma in situ (DCIS).
95
What are the surgical options for breast cancer?
The surgical options for breast cancer include mastectomy (removal of the entire breast) and wide local excision (removal of the tumor along with a margin of healthy tissue).
95
What is the purpose of sentinel lymph node biopsy in breast cancer?
Sentinel lymph node biopsy is often used to minimize the morbidity of an axillary dissection and assess the involvement of lymph nodes in breast cancer.
95
When is mastectomy preferred over wide local excision?
Mastectomy is preferred in cases of multifocal tumors, central tumors, large lesions in small breasts, DCIS larger than 4cm, or when there is a compelling indication for mastectomy due to the tumor's size.
95
What is the aim in terms of local recurrence rate for breast cancer surgery?
The aim of breast cancer surgery is to achieve a local recurrence rate of 5% or less at 5 years.
96
What is the Nottingham Prognostic Index used for?
The Nottingham Prognostic Index is used to give an indication of survival in breast cancer. It takes into account tumor size, lymph node involvement, and grade.
97
How is the Nottingham Prognostic Index calculated?
The Nottingham Prognostic Index is calculated by multiplying the tumor size by 0.2, adding the lymph node score (based on the number of lymph nodes involved), and adding the grade score (based on the tumor grade).
98
What is the 5-year survival rate based on the Nottingham Prognostic Index?
The 5-year survival rate based on the Nottingham Prognostic Index ranges from 93% for scores between 2.0 to 2.4, to 50% for scores above 5.4.
99
What factors are not included in the Nottingham Prognostic Index?
The Nottingham Prognostic Index does not include factors such as vascular invasion and receptor status, which can also impact survival and are often considered in the literature.
100
What are the different scores for lymph nodes involved and grade?
For lymph nodes involved: Score 1 for 0 lymph nodes, Score 2 for 1-3 lymph nodes, Score 3 for more than 3 lymph nodes. For grade: Score 1 for grade 1, Score 2 for grade 2, Score 3 for grade 3.
101
What is a phaeochromocytoma?
A phaeochromocytoma is a neuroendocrine tumor that originates from the chromaffin cells of the adrenal medulla.
102
What are common symptoms associated with phaeochromocytoma?
Hypertension (high blood pressure) and hyperglycemia (high blood sugar) are often found in patients with phaeochromocytoma.
103
What percentage of phaeochromocytoma cases are bilateral?
Approximately 10% of phaeochromocytoma cases are bilateral, meaning they affect both adrenal glands.
103
What percentage of phaeochromocytoma cases occur in children?
About 10% of phaeochromocytoma cases occur in children.
104
What percentage of phaeochromocytoma cases are malignant?
Approximately 11% of phaeochromocytoma cases are malignant, and the likelihood of malignancy is higher when the tumor is located outside the adrenal gland.
105
What percentage of phaeochromocytoma cases will not present with hypertension?
Around 10% of phaeochromocytoma cases will not present with hypertension.
106
What factors on CT scanning suggest benign adrenal lesions?
Factors on CT scanning that suggest benign adrenal lesions include a size smaller than 3cm, a homogeneous texture, lipid-rich tissue, and a thin wall to the lesion.
106
What is the recommended initial treatment for patients with phaeochromocytoma?
Patients with phaeochromocytoma require medical therapy as the initial treatment. An irreversible alpha adrenoreceptor blocker is typically given, although some may prefer reversible blockade. Labetolol may also be co-administered for cardiac chronotropic control.
107
How should incidental adrenal lesions be managed?
All patients with incidental adrenal lesions should be managed jointly with an endocrinologist. A full workup should be conducted, including urine analysis of vanillymandelic acid (VMA), blood testing for plasma metanephrine levels, and CT/MRI scanning to localize the lesion. Patients with functioning lesions or those with adverse radiological features, particularly a size larger than 3cm, should proceed to surgery.
107
How are adrenal lesions incidentally identified?
Adrenal lesions may be identified incidentally on CT scanning that is performed for other reasons.
108
What is primary hyperparathyroidism?
Primary hyperparathyroidism is a disorder characterized by elevated levels of parathyroid hormone (PTH) and calcium, along with low phosphate levels. It is often asymptomatic but can cause symptoms such as recurrent abdominal pain, changes in emotional or cognitive state, and complications like pancreatitis or renal colic. The majority of cases (80%) are due to a solitary adenoma, while 10-15% involve multifocal disease, and less than 1% are caused by parathyroid carcinoma.
109
What is secondary hyperparathyroidism?
Secondary hyperparathyroidism is characterized by elevated levels of PTH, along with low or normal calcium levels and elevated phosphate levels. Initially, there may be few symptoms, but over time, it can lead to bone disease, including osteitis fibrosa cystica, and soft tissue calcifications. It is commonly caused by parathyroid gland hyperplasia due to chronic renal failure and low calcium levels.
110
How does periductal mastitis differ from duct ectasia?
Periductal mastitis is a condition that typically occurs at a younger age compared to duct ectasia. It may present with features of inflammation, abscess, or the formation of a mammary duct fistula. Periductal mastitis is strongly associated with smoking. Treatment usually involves antibiotics, but drainage may be required for abscesses. It's important to note that periductal mastitis is not the same as duct ectasia.
110
What is tertiary hyperparathyroidism?
Tertiary hyperparathyroidism is characterized by normal or high calcium levels, elevated PTH levels, and decreased or normal phosphate levels. Other abnormalities may include decreased vitamin D levels and elevated alkaline phosphatase. Symptoms can include metastatic calcification, bone pain and fractures, nephrolithiasis, and pancreatitis. Tertiary hyperparathyroidism occurs as a result of ongoing hyperplasia of the parathyroid glands after correcting an underlying renal disorder, and it is often associated with hyperplasia of all four glands.
110
How is secondary hyperparathyroidism usually managed?
Secondary hyperparathyroidism is typically managed with medical therapy. Surgery is indicated in cases of secondary (renal) hyperparathyroidism when there are symptoms such as bone pain, persistent pruritus, or soft tissue calcifications.
110
What are the indications for surgery in primary hyperparathyroidism?
Indications for surgery in primary hyperparathyroidism include: elevated serum calcium levels more than 1mg/dL above normal, hypercalciuria exceeding 400mg/day, creatinine clearance less than 30% compared to normal, a history of life-threatening hypercalcaemia, nephrolithiasis, age under 50 years, neuromuscular symptoms, and a reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5).
110
What is a possible differential diagnosis for hypercalcaemia?
One possible differential diagnosis to consider for hypercalcaemia is benign familial hypocalciuric hypercalcaemia. This is a rare but relatively benign condition caused by an autosomal dominant genetic disorder. It can be distinguished from primary hyperparathyroidism by genetic testing and concordant biochemistry, specifically a urine calcium : creatinine clearance ratio of less than 0.01.
111
What is the recommended approach for treating tertiary hyperparathyroidism?
In cases of tertiary hyperparathyroidism, it is recommended to allow 12 months to elapse following a transplant, as many cases will resolve on their own. However, if there is an autonomously functioning parathyroid gland present, surgery may be required. If the specific problematic gland can be identified, it should be excised. Otherwise, total parathyroidectomy and re-implantation of part of the gland may be necessary.
112
What is a potential complication associated with axillary dissection during breast surgery?
One potential complication of breast surgery, specifically during axillary dissection, is long thoracic nerve injury. This can result in winging of the scapula.
113
What is the consequence of dividing the intercostobrachial nerves during breast surgery?
During breast surgery, the intercostobrachial nerves, which traverse the axilla, are often divided. This division can lead to an area of parasthesia in the armpit.
114
What can happen if there is injury to the thoracodorsal trunk during breast surgery?
Injury to the thoracodorsal trunk, which supplies the latissimus dorsi muscle, can occur during breast surgery. While the functional effects are not too serious, the main setback is that a latissimus dorsi flap cannot be used for reconstruction purposes.
115
What are the potential complications related to infections after breast surgery?
Infections are potential complications of breast surgery, especially if axillary nodal clearance is performed. Cellulitis of the chest wall and arm can be a major problem in such cases. Infections may require prolonged treatment with multiple therapies.
116
What is lymphoedema, and when does it typically occur after breast surgery?
Lymphoedema is a complication that typically occurs after axillary node clearance or irradiation during breast surgery. It is characterized by swelling and fluid retention. Treatment for lymphoedema involves manual lymphatic drainage and the use of compression sleeves.
117
What is a seroma, and how does it affect the site of surgery?
A seroma is an accumulation of fluid at the site of breast surgery. The fluid is usually straw-colored and may re-accumulate despite drainage. However, most seromas will resolve with time.
118
What is duct ectasia, and what are its common symptoms?
Duct ectasia is a condition characterized by the dilation of mammary ducts. It can be seen in up to 25% of normal female breasts. Patients with duct ectasia usually present with nipple discharge, which may come from single or multiple ducts. This condition is more commonly observed in women over the age of 50. The discharge is often thick and green in color. It's important to note that duct ectasia is a normal variant of breast involution and should not be confused with periductal mastitis.
119
What is an intraductal papilloma, and what are its common symptoms?
An intraductal papilloma refers to the growth of a papilloma within a single mammary duct. It usually presents with clear or blood-stained discharge originating from a single duct. It's important to note that intraductal papillomas do not increase the risk of malignancy.
120
What are some characteristics of tuberculosis affecting the breast?
Tuberculosis of the breast is rare in western countries and is usually secondary to tuberculosis in other parts of the body. It tends to affect women later in their childbearing period. Chronic breast or axillary sinus is present in up to 50% of cases. Diagnosis is typically made through biopsy culture and histology.
121
What is a common cause of breast abscesses, and how are they treated?
Breast abscesses are commonly associated with lactational mastitis. The infection is usually caused by Staphylococcus aureus. On examination, a tender fluctuant mass is often observed. Treatment for breast abscesses involves antibiotics and ultrasound-guided aspiration. If there is overlying skin necrosis, surgical debridement may be necessary. However, this can be complicated by the development of a subsequent mammary duct fistula.
122
What is the recommended approach for assessing patients with thyroid disease?
The assessment of patients with thyroid disease involves taking a detailed history, conducting a physical examination, and performing an ultrasound scan. If a thyroid nodule is identified, it should ideally be sampled through an image-guided fine needle aspiration. Radionuclide scanning has limited use in this context.
123
What are some types of thyroid tumors?
Thyroid tumors can include papillary carcinoma, follicular carcinoma, anaplastic carcinoma, medullary carcinoma, and lymphomas.
124
How are patients with endocrine dysfunction in thyroid disease managed?
Patients with endocrine dysfunction in thyroid disease are typically managed by physicians initially. Surgery may be offered alongside radioiodine treatment for patients with Graves' disease who do not respond to medical management or for those who prefer not to undergo irradiation, such as pregnant women. Patients with hypothyroidism generally do not undergo thyroidectomy. In some cases of Hashimoto's thyroiditis, patients may inadvertently be offered resections during the early phase. However, as the toxic phase passes, these patients can be managed with thyroxine.
124
What is multinodular goitre, and how is it managed?
Multinodular goitre is a common reason for presentation in thyroid disease. If the patient is euthyroid, asymptomatic, and no discrete nodules are seen, reassurance can be provided. However, if the patient experiences compressive symptoms, surgery in the form of a total thyroidectomy is required. Subtotal resections, which were previously performed, often lead to recurrent disease and necessitate difficult revisional resections.
124
What are some possible complications following thyroid surgery?
Complications following thyroid surgery can include anatomical issues such as recurrent laryngeal nerve damage, bleeding leading to respiratory compromise, and damage to the parathyroid glands resulting in hypocalcemia.
125
When is delayed primary closure used, and how does it differ from primary closure?
Delayed primary closure employs similar methods of actual closure to primary closure. It is used when primary closure is either not achievable or not advisable, such as in the presence of infection. Delayed primary closure allows for adequate wound preparation and resolution of infection before closure is performed.
125
What is the indication for primary closure as a method of wound closure?
Primary closure is indicated for clean wounds, typically those that are surgically created or result from minor trauma. Standard suturing methods are usually sufficient for primary closure. Wounds that heal by primary intention are closed without delay.
126
What is the vacuum-assisted closure method, and what are its advantages and disadvantages?
Vacuum-assisted closure involves negative pressure therapy to facilitate wound closure. A sponge is inserted into the wound cavity, and negative pressure is applied. This method has advantages such as removal of exudate and versatility. However, disadvantages include cost and the risk of fistulation if used incorrectly in certain sites, such as the bowel.
127
What is the process and purpose of split thickness skin grafts?
Split thickness skin grafts involve removing the superficial dermis using a Watson knife or dermatome, commonly from the thigh. The remaining epithelium regenerates from dermal appendages. Meshing can increase coverage.
128
How does a full thickness skin graft differ from a split thickness skin graft?
In a full thickness skin graft, the entire dermal thickness is removed. Subdermal fat is also removed, and the graft is placed over the donor site. Full thickness skin grafts offer better cosmesis and flexibility at the recipient site but may result in donor site morbidity.
129
What are flaps as a method of wound closure, and what are the differences between pedicled and free flaps?
Flaps involve using viable tissue with a blood supply to close a wound. Flaps can be either pedicled or free. Pedicled flaps are more reliable but have a limited range. Free flaps have a greater range but carry a higher risk of breakdown as they require vascular anastomosis.
130
What are some considerations for preparing elective surgery patients?
For elective cases, it is important to consider addressing any medical issues through a pre-admission clinic. Blood tests, such as a full blood count (FBC), kidney and liver function tests (U+E, LFTs), clotting profile, and blood grouping and saving, should be performed. Additionally, a urine analysis, pregnancy test, and sickle cell test may be necessary. Other tests, such as an ECG or chest x-ray, may be performed based on the proposed procedure and the patient's fitness. Risk factors for deep vein thrombosis should be assessed, and a plan for thromboprophylaxis should be formulated.
131
How should diabetic patients be managed in preparation for surgery?
Diabetic patients have a higher risk of complications, especially if their diabetes is poorly controlled. For patients with diet or tablet-controlled diabetes, a policy of omitting medication and regularly checking blood glucose levels may be sufficient. Diabetics who are poorly controlled or take insulin may require an intravenous sliding scale for glucose management. Potassium supplementation should also be considered. Diabetic cases should be prioritized and operated on first.
132
What should be considered when preparing for emergency surgery?
For emergency cases, the focus is on stabilizing and resuscitating the patient if needed. The need for antibiotics should be assessed, and administration should be determined. If major procedures are planned, especially in the presence or anticipation of coagulopathies (e.g., ruptured AAA repair), the blood bank should be informed. Consent and communication with relatives should not be overlooked.
132
Are there any special preparations for specific surgical procedures?
Yes, some procedures require special preparation. For thyroid surgery, a vocal cord check is necessary. In parathyroid surgery, methylene blue may be considered to identify the gland. Sentinel node biopsy may require the use of a radioactive marker or patent blue dye. Surgery involving the thoracic duct may involve the administration of cream. Pheochromocytoma surgery will require alpha and beta blockade. Surgery for carcinoid tumors will need to be covered with octreotide. For colorectal cases, bowel preparation, especially for left-sided surgery, is important. For thyrotoxicosis, lugols iodine or medical therapy may be needed.
133
What are the common treatment options for breast cancer?
The common treatment options for breast cancer include surgery, chemotherapy, hormonal therapy, and radiotherapy.
134
What is the purpose of chemotherapy and hormonal therapy in breast cancer management?
Chemotherapy and hormonal therapy may be used to downstage tumors and allow for breast-conserving surgery.
135
When is radiotherapy typically given in breast cancer management?
Radiotherapy is given to most patients who have undergone breast-conserving surgery. However, older patients receiving hormone treatment and those with small, low-grade tumors may safely avoid radiotherapy.
136
What is therapeutic mammoplasty?
Therapeutic mammoplasty is an option for some breast cancer patients. It involves a combination of tumor removal and symmetrizing surgery.
137
What options are available for patients who have undergone mastectomy?
Patients who have undergone mastectomy may be offered a reconstructive procedure either during their primary resection or as a staged procedure at a later date.
138
What factors are considered when deciding between mastectomy and wide local excision?
Factors considered when deciding between mastectomy and wide local excision include the presence of multifocal tumors, central or peripheral tumor location, size of lesion relative to breast size, and the extent of ductal carcinoma in situ (DCIS).
Surgical options
Mastectomy vs Wide local excision
Mastectomy Wide Local Excision
Multifocal tumour Solitary lesion
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast
DCIS >4cm DCIS <4cm
Patient Choice Patient choice
139
How is axillary nodal involvement assessed in breast cancer patients?
As a minimum, all patients with invasive breast cancer should have their axilla staged. This can be done using sentinel lymph node biopsy in patients without overt evidence of axillary nodal involvement.
140
What are the potential risks associated with axillary node clearance?
Axillary node clearance is associated with the development of lymphedema, an increased risk of cellulitis, and frozen shoulder.
140
What are the considerations for managing central lesions in breast cancer patients?
Central lesions may be managed using breast-conserving surgery in cases where an acceptable cosmetic result can be achieved. However, this is rarely the case in small breasts.
141
What are the options for axillary node management in breast cancer patients?
Patients with a positive sentinel lymph node biopsy or evidence of axillary nodal metastasis should undergo axillary node clearance or axillary irradiation.
141
What are some common causes of hyperthyroidism?
Common causes of hyperthyroidism include diffuse toxic goiter (Graves Disease), toxic nodular goiter, toxic nodule, and rare causes.
142
What is Graves disease?
Graves disease is a form of hyperthyroidism characterized by a diffuse vascular goiter that appears simultaneously with the clinical manifestations of hyperthyroidism. It is most common in younger females and may be associated with eye signs.
143
What is the underlying mechanism of Graves disease?
Graves disease is caused by thyroid-stimulating effects of TSH receptor antibodies, leading to glandular hypertrophy and hyperplasia.
144
What is toxic nodular goiter?
Toxic nodular goiter is a disorder where the goiter is present for a long period of time before the development of clinical symptoms. In some cases, the internodular tissue, rather than the nodules themselves, is responsible for the hyperthyroidism.
145
What is a toxic nodule?
A toxic nodule refers to an overactive, autonomously functioning nodule in the thyroid. It can occur as part of generalized nodularity or as a true toxic adenoma. TSH levels are usually low due to negative feedback from the autonomously functioning thyroid tissue.
146
What are the signs and symptoms of hyperthyroidism?
Signs and symptoms of hyperthyroidism include lethargy, tachycardia, emotionally labile, agitation, heat intolerance, weight loss, excessive appetite, palpitations, exophthalmos, and thyroid goiter and bruit.
147
What is the most sensitive test for diagnosing hyperthyroidism?
The most sensitive test for diagnosing hyperthyroidism is plasma T3, which is typically elevated. TSH levels of less than 0.5U/L also suggest hyperthyroidism.
148
What is the first-line treatment for Graves disease?
The first-line treatment for Graves disease is usually medical, and the block and replace regime is the favored option. This involves administering carbimazole at higher doses and orally administering thyroxine. Patients are typically maintained on this regime for 6 to 12 months, with attempts made to wean off the medication afterward.
149
What are the options for treatment if Graves disease relapses after initial treatment?
If Graves disease relapses after initial treatment, the options include ongoing medical therapy, radioiodine, or surgery. The choice depends on the individual's condition and preferences.
150
What are some causes of nipple discharge?
Some causes of nipple discharge include physiological changes during breastfeeding, galactorrhea (which can be a response to emotional events or certain medications), hyperprolactinemia (commonly caused by pituitary tumors), mammary duct ectasia (dilation of breast ducts, most common in menopausal women), carcinoma (often associated with blood-stained discharge and may indicate an underlying mass or axillary lymphadenopathy), and intraductal papilloma (more common in younger patients and may cause blood-stained discharge without a palpable lump).
151
What is galactorrhea?
Galactorrhea is a common cause of nipple discharge and is often a response to emotional events. It can also be caused by certain medications, such as histamine receptor antagonists.
152
What is the most common type of pituitary tumor associated with hyperprolactinemia?
The most common type of pituitary tumor associated with hyperprolactinemia is microadenomas, which are tumors smaller than 1cm in diameter. Larger tumors, called macroadenomas, are also associated with hyperprolactinemia and can cause pressure on the optic chiasm, leading to bitemporal hemianopia.
153
What is mammary duct ectasia?
Mammary duct ectasia refers to the dilation of breast ducts and is most commonly seen in menopausal women. The discharge associated with this condition is typically thick and green in color. It is also more common in smokers.
154
What are the characteristics of nipple discharge associated with carcinoma?
Nipple discharge associated with carcinoma is often blood-stained. It may indicate an underlying mass or axillary lymphadenopathy.
155
What is an intraductal papilloma?
An intraductal papilloma is a common cause of nipple discharge, especially in younger patients. It may cause blood-stained discharge without a palpable lump.
156
What is the first step in assessing patients with nipple discharge?
The first step in assessing patients with nipple discharge is to examine the breast and determine whether there is a mass lesion present.
157
What is Triple assessment?
Triple assessment is a comprehensive approach that all mass lesions should undergo. It typically includes clinical examination, imaging (such as mammography), and a biopsy or cytology sample.
158
How are investigations for a suspected mass lesion reported?
Investigations for a suspected mass lesion are reported using a system that denotes the investigation type. For example, mammography is prefixed with the letter "M" followed by a numerical code. The numerical codes indicate the findings, ranging from no abnormality (1) to malignant (5).
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
159
What should be done to manage non-malignant nipple discharge?
To manage non-malignant nipple discharge, it is important to exclude endocrine diseases. Nipple cytology is unhelpful in this case. Smoking cessation advice is given for duct ectasia. In cases of duct ectasia with severe symptoms, total duct excision may be warranted.
160
What are some biological agents used in medical treatments?
Some biological agents used in medical treatments include adalimumab, infliximab, etanercept, bevacizumab, trastuzumab, imatinib, basiliximab, and cetuximab.
160
What is the target of adalimumab, infliximab, and etanercept?
Adalimumab, infliximab, and etanercept are TNF alpha inhibitors. They are used to treat conditions such as Crohn's disease and rheumatoid disease.
161
What is the target of bevacizumab?
Bevacizumab is an anti-VEGF (anti-angiogenic) agent. It is used to treat conditions such as colorectal cancer, renal cancer, and glioblastoma.
161
What is the target of trastuzumab?
Trastuzumab targets the HER receptor and is used in the treatment of breast cancer.
162
What is the target of basiliximab?
Basiliximab targets the IL2 binding site and is used in renal transplants.
163
What is the target of cetuximab?
Cetuximab is an epidermal growth factor inhibitor. It is used in the treatment of EGF-positive colorectal cancers.
163
What is the target of imatinib?
Imatinib is a tyrosine kinase inhibitor. It is used in the treatment of gastrointestinal stromal tumors and chronic myeloid leukemia.
164
What is the scope of understanding required for biological agents in the MRCS syllabus?
Detailed understanding of the actions of biological agents is beyond the scope of the MRCS syllabus. However, these drugs are frequently encountered in surgical patients.
165
What is the major immediate risk following thyroidectomy?
The major immediate risk following thyroidectomy is haemorrhage.
166
What can result from a tension haematoma deep to the cervical fascia?
A tension haematoma deep to the cervical fascia can result in the development of laryngeal oedema and airway compromise.
167
How is a tension haematoma treated?
A tension haematoma is treated by urgent wound decompression of all layers prior to return to theatre for haemostasis.
168
What are subcutaneous haematomas and seromas?
Subcutaneous haematomas and seromas may accumulate under skin flaps. They can often be managed conservatively or by simple aspiration.
168
What is the risk in patients with longstanding large goitres?
In patients with longstanding large goitres, there is a risk of tracheomalacia, characterized by the development of flaccidity of the tracheal cartilage. This can result in airway compromise.
169
What is the management for airway compromise in tracheomalacia?
In the immediate situation of airway compromise in tracheomalacia, an endotracheal tube will need to be inserted.
170
What is a recognized complication following thyroid surgery?
Hypoparathyroidism is a recognized complication following thyroid surgery.
170
What is the risk of recurrent laryngeal nerve injury following thyroid surgery?
The risk of recurrent laryngeal nerve injury following thyroid surgery is 1.8% at one month, declining to 0.5% at three months after the first exploration.
171
What is the common cause of hypoparathyroidism after thyroid surgery?
Damage to the blood supply to the parathyroid glands is probably the commonest cause of hypoparathyroidism after thyroid surgery.
172
How is hypoparathyroidism treated in the emergency setting?
In the emergency setting, hypoparathyroidism is treated with intravenous calcium gluconate.
172
What is the incidence of permanent hypoparathyroidism following thyroid surgery?
The incidence of permanent hypoparathyroidism following thyroid surgery is in the region of 1 to 3%.
173
What is used for the longer-term treatment of hypoparathyroidism?
For the longer-term treatment of hypoparathyroidism, oral calcium carbonate is used.
174
What is the mechanism of action of tamoxifen?
Tamoxifen is a synthetic partial estrogen agonist that primarily acts by binding to the estrogen receptor.
174
How long does it take for tamoxifen to reach plasma steady state?
It takes 4 weeks for tamoxifen to reach plasma steady state.
174
In which patients should tamoxifen usually be considered?
Tamoxifen should usually be considered in patients with estrogen receptor positive tumors. However, alternative agents may be preferred in some groups.
174
What is the half-life of tamoxifen?
The half-life of tamoxifen is 7 days.
175
What are the common climacteric side effects of tamoxifen?
Common climacteric side effects of tamoxifen include hot flashes and other menopausal symptoms.
175
What are the potential effects of tamoxifen on different sites in the body?
While tamoxifen is antagonistic with respect to breast tissue, it may serve as an agonist at other sites. This can result in an increased risk of endometrial cancer, preservation of bone density, and decreased cardiovascular risks.
176
What are the alternative drugs to tamoxifen?
Aromatase inhibitors are an alternative class of drugs to tamoxifen. They work by blocking the peripheral aromatization of androgens, which is how postmenopausal women produce estrogens. Aromatase inhibitors may be used to treat cancers for which tamoxifen is no longer effective.
177
What is the underlying cause of lymphoedema?
Lymphoedema is caused by impaired lymphatic drainage in the presence of normal capillary function.
178
What are the characteristic features of lymphoedema?
Lymphoedema causes the accumulation of protein-rich fluid, subdermal fibrosis, and dermal thickening. The fluid is confined to the epifascial space (skin and subcutaneous tissues), while muscle compartments remain free of edema. Unlike other forms of edema, lymphoedema involves the foot and may present with a 'buffalo hump' on the dorsum of the foot. The skin cannot be pinched due to subcutaneous fibrosis.
179
What are the causes of primary lymphoedema based on age of onset?
Primary lymphoedema can be categorized based on the age of onset: congenital (< 1 year) may be sporadic or due to Milroy's disease, onset between 1-35 years may be sporadic or due to Meige's disease, and onset after 35 years is called Tarda.
180
What are the causes of secondary lymphoedema?
Secondary lymphoedema can be caused by bacterial/fungal/parasitic infections (such as filariasis), lymphatic malignancy, radiotherapy to lymph nodes, surgical resection of lymph nodes, deep vein thrombosis (DVT), and thrombophlebitis.
180
What are the indications for surgery in lymphoedema?
Surgery may be indicated in cases of lymphoedema with marked disability or deformity from limb swelling. It is also considered for lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure, as well as for cases with lymphocutaneous fistulae and megalymphatics.
181
What is the Homans operation for lymphoedema?
The Homans operation is a surgical procedure that involves raising skin flaps and excising underlying tissue to reduce limb circumference by about a third. It is performed in cases where the overlying skin is in good condition.
181
What is the Charles operation for lymphoedema?
The Charles operation is a surgical procedure that involves excising all the skin and subcutaneous tissue around the calf down to the deep fascia. Split skin grafts are then placed over the site. It may be performed when the overlying skin is not in good condition and results in a larger reduction in size compared to the Homans procedure.
182
What is a lymphovenous anastomosis?
Lymphovenous anastomosis is a surgical procedure where identifiable lymphatics are anastomosed to subdermal venules. It is typically indicated in about 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.
182
What is subacute thyroiditis?
Subacute thyroiditis, also known as De Quervain's thyroiditis, is a condition that is believed to occur following a viral infection. It is characterized by hyperthyroidism.
183
What are the features of subacute thyroiditis?
Subacute thyroiditis presents with hyperthyroidism, a painful goiter, raised ESR (erythrocyte sedimentation rate), and globally reduced uptake on an iodine-131 scan.
184
Is treatment required for subacute thyroiditis?
Subacute thyroiditis is usually self-limiting, and most patients do not require treatment. However, thyroid pain may respond to aspirin or other NSAIDs. In more severe cases, steroids may be used, especially if hypothyroidism develops.
184
What is Hashimoto's thyroiditis?
Hashimoto's thyroiditis is an immunological disorder in which lymphocytes become sensitized to thyroidal antigens. It is characterized by the presence of three important antibodies: thyroglobulin, TPO (thyroid peroxidase), and TSH-R (thyrotropin receptor).
185
What are the features of Hashimoto's thyroiditis?
Hashimoto's thyroiditis presents with a goiter and can either be associated with euthyroidism (normal thyroid function) or mild hypothyroidism. As the disease progresses, hypothyroidism may develop, along with associated symptoms.
186
What is the management for Hashimoto's thyroiditis?
During the hyperthyroid phase of Hashimoto's thyroiditis, beta blockers may be used to manage symptoms. As hypothyroidism develops, patients may require thyroxine supplementation.
187
Why have incidental adrenal lesions become more common?
Incidentalomas of the adrenal glands have become increasingly common due to the widespread use of CT scanning of the abdomen.
188
What percentage of incidental adrenal lesions are non-functioning adenomas?
Approximately 75% of incidental adrenal lesions are non-functioning adenomas.
189
What investigations are conducted to exclude a functioning lesion in incidental adrenal lesions?
Investigations to exclude a functioning lesion in incidental adrenal lesions include morning and midnight plasma cortisol measurements, a dexamethasone suppression test, 24-hour urinary cortisol excretion, 24-hour urinary excretion of catecholamines, and measurement of serum potassium, aldosterone, and renin levels.
190
What is the management approach for incidental adrenal lesions?
The risk of malignancy in incidental adrenal lesions is related to the size of the lesion. Masses greater than 4cm have a 25% chance of being malignant and should usually be excised. If a lesion is suspected to be a metastatic deposit, a biopsy may be considered.
