23-25 Parathyroid, Breast, Thoracic Flashcards
1
Q
Where do the superior parathyroid originate? and inferior?
A
4th pharyngeal pouch, 3rd pharyngeal pouch
2
Q
Where are the superior parathyroids in relation to the RLNs? and the inferior?
A
lateral, medial
3
Q
Where are the superior parathyroids in relation to the inferior thyroid artery? and inferior parathyroids?
A
above, below
4
Q
What is the blood supply to the parathyroids?
A
inferior thyroid artery
5
Q
What is the most common ectopic site for parathyroids?
A
tail of the thymus
6
Q
What is a normal Ca level range?
A
8.5-10.5
7
Q
What is a normal PTH level range?
A
5-40
8
Q
What is the most common cause of hypoparathyroidism?
A
previous thyroid surgery
9
Q
What is the name form bone lesions from Ca resorption; characteristic of hyperparathyroidism?
A
Osteitis firbrosa cystica (brown tumors)
10
Q
Indications for parathyroid surgery include symptomatic disease or asymptomatic disease with Ca above what level?
A
13
11
Q
What percentage of pts with hyperparathyroid have single adenoma? multiple adenomas? diffuse hyperplasia?
A
single adenoma 80%
multiple adenomas 4%
diffuse hyperplasia 15%
12
Q
Hyperparathyroidism in pregnancy carries a risk of still birth. In what trimester do you operate?
A
2nd
13
Q
What is the half-life of PTH?
A
10 minutes
14
Q
What should be done if parathyroid CA is found?
A
radical parathyroidectomy and take ipsilateral thyroid
15
Q
What are the three causes of postop hypocalcemia after parathyroid surgery?
A
bone hunger, hypomagnesmia, failure of parathyroid remnant or graft
16
Q
Hypocalcemia postop after parathyroid surgery. What will the levels of PTH and HCO3- be if the cause is bone hunger? and what if it is aparathyroidism?
A
Bone hunger – normal PTH, decreased HCO3− Aparathyroidism – decreased PTH, normal HCO3−
17
Q
What is the study that is used in hyperparathyroidism that is good for picking up adenomas and ectopic glands but not 4-gland hyperplasia?
A
sestamibi-technetium-99
18
Q
What is the most common indication for surgery in secondary hyperparathyroidism?
A
bone pain
19
Q
What diagnosis should you consider if pt has Ca 9–11, normal PTH (30–60), ↓ urine Ca?
A
Familial hypercalcemic hypocalciuria
20
Q
What is the cause of familial hypercalcemic hypocalciuria?
A
Caused by defect in PTH receptor in distal convoluted tubule of the kidney that causes ↑ resorption of Ca
21
Q
What is the tx for familial hypercalcemic hypocalciuria?
A
Nothing, no parathyroidectomy because Ca generally not that high
22
Q
What is the most common location for metastases of parathyroid cancer?
A
the lung
23
Q
List the MEN syndromes and components?
A
MEN I: parathyroid hyperplasia, pancreatic islet cell tumors, pituitary adenomas
MEN IIa: parathyroid hyperplasia, pheochromocytoma, medullary CA of the thyroid
MEN IIb: pheochromocytomas, medullary CA of thyroid, mucosal neuromas, marfan’s habitus
24
Q
Name the drug used in the management of hypercalcemia that inhibits osteoclasts (used with malignancies or failure of conventional treatment); has hematologic, liver, and renal side effects.
A
Mithramycin
25
When breast CA metastases to bone, what causes hypercalcemia?
release of PTHrp
26
What hormone is responsible for duct development of the breast? and lobular development? and what hormone synergizes those two?
estrogen, progesterone, prolactin
27
What nerve innervates serratus anterior; injury results in winged scapula?
long thoracic
28
What artery supplies serratus anterior?
lateral throacic artery
29
What nerve innervates latissimus dorsi?
thoracodorsal nerve
30
What artery supplies latissimus dorsi?
thoracodorsal artery
31
What innervates pectoralis major and minor? what innervates pectoralis major only?
Medial pectoral nerve – innervates pectoralis major and pectoralis minor • Lateral pectoral nerve – pectoralis major only
32
What nerve?:
Lateral cutaneous branch of the 2nd intercostal nerve; provides sensation to medial arm and axilla; encountered just below axillary vein when performing axillary dissection. Can transect without serious consequences.
intercostobrachial nerve
33
Branches of 4 arteries supply the breast?
internal thoracic artery, intercostal arteries, thoracoacromial artery, and lateral thoracic artery
34
What is the valveless vein plexus that allows direct hematogenous metastasis of breast CA to spine?
Batson's plexus
35
What is the number 1 cause of axillary adenopathy?
lymphoma
36
What is the term used to describe breast cysts filled with milk; occurs with breast-feeding? Tx: ranges from aspiration to incision and drainage.
Galactocele
37
Dilated mammary ducts, inspissated secretions, marked periductal inflammation • Symptoms: noncyclical mastodynia, nipple retraction, creamy discharge from nipple; can have sterile subareolar abscess • Patients have a history of difficulty with breast-feeding • Tx: if typical creamy discharge is present that is not bloody and not associated with nipple retraction, may be able to reassure; otherwise need to rule out malignancy.
Periductal mastitis (mammary duct ectasia or plasma cells mastitis)
38
What syndrome is described by hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle?
Poland's syndrome
39
Name the disease and treatment described by superficial vein thrombophlebitis of breast; feels cordlike, can be painful • Associated with trauma and strenuous exercise • Usually occurs in lower outer quadrant.
Mondor's disease, tx NSAIDs
40
What are the two types of fibrocystic breast disease that have a cancer risk?
atypical ductal or lobular hyperplasia
41
What type of fibrocystic disease can manifest as a cluster of calcifications on mammogram without a mass or pain → can look like breast CA? • Is differentiated from breast CA by regularity of nuclei and absence of mitoses
sclerosing adenosis
42
What is the most common cause of bloody discharge from nipple?
intraductal papilloma
43
Are intraductal papillomas premalignant?
no
44
How to locate a intraductal papilloma and what is the tx?
→ can get contrast ductogram to find papilloma • Tx: resection (subareolar resection usually curative)
45
What is the most common breast lesion in adolescents and young women?
fibroadenoma
46
How do you diagnose a fibroadenoma in a pt 30?
In patients < 30 years:
• Mass needs to feel clinically benign (firm, rubbery, rolls, not fixed)
• Ultrasound or mammogram needs to be consistent with fibroadenoma
• Need fine-needle aspiration (FNA) or core needle biopsy showing the lesion (not just normal breast tissue.
In patients > 30 years → excisional biopsy to ensure diagnosis
47
What is the difference in workup for nipple discharge that is spontaneous vs nonspontaneous?
Spontaneous discharge – no matter what the color or consistency is worrisome for cancer • All these patients need some sort of biopsy in the area of the duct causing the discharge
Nonspontaneous discharge (occurs only with pressure, tight garments, exercise, etc.) – not as worrisome but may still need excisional biopsy (i.e., if bloody)
48
What two things do all pts with nipple discharge need?
H and P and bilateral mammogram
49
What is the usual cause of green nipple discharge and tx?
Usually due to fibrocystic disease. Tx: if cyclical and nonspontaneous, reassure pt
50
What are two possible causes of bloody nipple discharge and their workup?
Bloody discharge – most commonly intraductal papilloma; occasionally ductal CA • Tx: need galactogram and excision of that ductal area
51
What is the concern with serous nipple discharge and the tx?
Serous discharge – worrisome for cancer, especially if coming from only 1 duct or spontaneous • Tx: excisional biopsy of that ductal area
52
■ Affects multiple ducts of both breasts ■ Papillomas are larger than when they occur solitarily ■ Usually have serous discharge ■ Mammogram shows Swiss cheese appearance ■ ↑ risk of breast CA (40% get breast CA)
Diffuse Papillomatosis
53
■ Malignant cells of the ductal epithelium without invasion of the basement membrane ■ 50%–60% get cancer if not resected (ipsilateral breast); 5%–10% get cancer in contralateral breast ■ Considered a premalignant lesion ■ Usually not palpable and presents as a cluster of calcifications on mammography
Ductal Carcinoma In Situ
54
What size margin is needed for ductal carcinoma in situ?
2-3 mm
55
What is the most aggressive subtype of ductal carcinoma in situ; has necrotic areas • High risk for multicentricity, microinvasion, and recurrence • Tx: simple mastectomy
Comedo pattern
56
What is the tx for ductal carcinoma in situ with a small focus? and if high grade (ie comedo type, multicentric, multifocal)?
small focus: lumpectomy and XRT; possibly tamoxifen
simple mastectomy if high grade or large tumor; no ALND
57
■ 40% get cancer (either breast) ■ Considered a marker for the development of breast CA, not premalignant itself ■ Has no calcifications; is not palpable ■ Primarily found in premenopausal women, usually incidental finding
Lobular carcinoma in situ
58
What are three treatment options for lobular carcinoma in situ?
Tx: nothing, tamoxifen, or bilateral subcutaneous mastectomy (no ALND)
59
What country has the lowest rate of breast CA worldwide?
Japan
60
Is breast CA increased or decreased in economically poor areas?
decreased
61
What is the breast CA risk for women?
1 in 8 (12%)
62
What is the median survival for untreated breast CA
2-3 years
63
What percentage of breast CAs have negative mammogram and negatie ultrasound?
10%
64
Symptomatic breast mass in a pt <30 years old, what next?
ultrasound
65
Symptomatic breast mass in a pt <30 years old, gets ultrasound and it shows it is solid, what next?
FNA
66
Symptomatic breast mass in a pt <30 gets ultrasound, shows solid, has FNA, it comes back nondiagnostic, what next? what if FNA comes back fibroadenoma
excisional bx, fibroadenomas need excisional bx if enlarges
67
Symptomatic breast mass in pt 30-50 years what next?
bilateral mammograms and FNA; excisional bx if FNA nondiagnostic
68
Symptomatic breast mass in a pt >50 years what next?
bilateral mammograms and excisional or core needl bx
69
What is the difference in FNA and core needle bx.
Core needle bx gives architecture, FNA gives cytology (just the cells)
70
Symptomatic breast mass is cystic, fluid is bloody what next? what if is clear and recurs? what if complex cyst?
excisional bx for all three: bloody, recurs, or complex
71
What size does a mass need to be in order to be detected on mammogram?
>5mm
72
What are the general screening mammogram guidelines? and for high risk?
Every 2-3 years after age 40, yearly after 40
High risk: 10 years before the youngest age of dx in first-degree relative
73
What is the next step if mammogram shows suspicious or indeterminate calcifications or architecture?
perform localized stereotactic needle excisional biopsy
74
Name the BI-RADS level:
Highly suggestive of malignancy. High probability of cancer; appropriate action should be taken.
5
75
Name the BI-RADS level:
Suspicious abnormality. Definite probability of malignancy; consider biopsy
4
76
Name the BI-RADS level:
Probably benign finding Short-interval follow-up
3
77
What muscle divides the three axillary lymph node levels and what are they?
```
Pec Minor
I – lateral to pectoralis minor muscle
II – beneath pectoralis minor muscle
III – medial to pectoralis minor muscle
```
78
What is the most important prognostic staging factor in breast CA? list 4 others?
nodes
tumor size, tumor grade, progesterone and estrogen status
79
What is the most common distant metastasis for breast CA? list 3 others?
bone
lung, liver, brain
80
With breast cancer, how long does it take to go from one malignant cell to a 1 cm tumor?
5-7 years
81
Central and subareolar tumors have an increased risk of what?
multcentricity
82
What type are 85% of breast CAs? and the next 10%?
ductal CA, lobular CA
83
What is the median survival for inflammatory breast cancer?
36 months
84
What causes the peu d'orange appearance in inflammatory breast cancer?
dermal lymphatic invasion
85
Subcutaneous (simple) mastectomy preserves the nipple and leaves 1-2% of breast tissue. Not indicated for breast CA treatment. Used for what two conditions?
DCIS and LCIS
86
What size margins for lumpectomy?
1 cm
87
Clinically positive nodes not a candidate for SLND, needs what?
ALND
88
During SLND, if no radiotracer or dye is found, what do you do?
ALND
89
A complication of axillary lymph node dissection, sudden early, postop swelling could be do to what? what about slow swelling over 18 months?
Axillary vein thrombosis, Lymphatic fibrosis
90
A complication of axillary lymph node dissection: hyperesthesia of inner arm and lateral chest wall; most commonly injured nerve after mastectomy; no significant sequelae. What nerve could be injured?
Intercostal brachiocutaneous
91
How long to leave drains after axillary lymph node dissection?
until drainage < 40cc/day
92
```
Indications for XRT after mastectomy include:
?
skin or chest wall involvement
positive margins
tumor > what size?
extracapsular node invasion
inflammatory CA
fixed nodes or internal mammary nodes
```
>4 nodes
| >5 cm tumor
93
Lumpectomy with XRT pts need what before starting XRT?
negative margins
94
Two indications for chemo in breast CA
• Positive nodes – everyone gets chemo except postmenopausal women with positive estrogen receptors → tamoxifen • >1 cm and negative nodes – everyone gets chemo except patients with positive estrogen receptors → tamoxifen • <1 cm and negative nodes – no further treatment
95
With paget's disease of the breast, pts will have what 2 other conditions?
DCIS or ductal CA
96
What is the tx for Paget's disease of the breast?
MRM if CA present otherwise simple mastectomy
97
Cystosarcoma phyllodes, 10% are malignant, how can it mets?
hematogenous (rare), no nodal mets
98
What is the tx for Cystosarcoma phyllodes?
WLE with negative margins, no ALND
99
What is the name for the syndrome which is lymphangiosarcoma from chronic lymphedema following axillary dissection (MRM) • Patients present with dark purple nodule or lesion on arm 5–10 years after surgery
Stewart-Treves syndrome
100
What is the position of the phrenic nerve and vagus nerve in the hilum?
■ Phrenic nerve – runs anterior to hilum
| ■ Vagus nerve – runs posterior to hilum
101
What percentage of total lung volume is from the right lung?
55%
102
What percentage of quiet inspiration is from the diaphragm? and the intercostals?
80%, 20%
103
Which pneumocytes produce surfactant?
Type II
104
What structures direct air exchange between alveoli?
Pores of Kahn
105
How much pleural fluid is produced per day?
1-2 L
106
Which layer of the pleura produces pleural fluid and which layer has the lymphatics that clear the fluid?
parietal pleura produces pleural fluid cleared by lymphatics in the visceral pleura
107
What is the most common single site of lung CA mets?
brain
108
What is the overall 5 year survival rate for lung CA? and with resection?
10%, 30%
109
What is the most common type of lung CA?
adenocarcinoma
110
Local recurrence is increased with which type of lung CA? and distant metastases?
local recurrence, distant metastases
111
What percentage of pts with small carcinoma are surgical candidates?
<5% (most get just chemo and XRT)
112
What is the most common paraneoplastic syndrome?
Small cell ACTH
113
What is the most malignant lung tumor?
mesothelioma
114
Name two chemotherapy agents used for small cell lung CA
cisplatin, etopside
115
What is the name of the procedure used to assess aortopulmonary window nodes; goes through left 2nd rib cartilage?
Chamberlain procedure
116
In addition to Horner's syndrome, what other nerve can have sx with Pancoast tumor?
ulnar
117
Coin lesions are overall 5-10% malignant. Age 50?
<5%, 50%
118
What type of tumor is carcinoids? what is the tx?
neuroendocrine, tx: resection; treat like CA
119
Name the lung mass:
• Submucosal glands; spread along perineural lymphatics, well beyond endoluminal component; XRT sensitive • Slow growing; can get 10-year survival with incomplete resection • Tx: resection; if unresectable, XRT can provide good palliation
Adenoid cystic adenoma
120
What is the most common benign adule lung tumor?
hamartoma
121
Popcorn lesion on chest CT, dx? tx?
hamartoma, Do not require resection ■ Repeat chest CT in 6 months to confirm diagnosis
122
What type of tumor is the most common mediastinal tumor in adults and children, usually in posterior mediastinum?
neurogenic tumors
123
What is the most common site for mediastinal tumor?
anterior (thymus)
124
What are 5 types of tumors found in the anterior mediastinum?
```
Thymoma,
Thyroid CA and goiters,
T-cell lymphoma,
Teratoma,
Parathyroid adenomas
```
125
What is the tx for all thymomas?
resection
126
What is the tx for mediastinal teratoma? and seminoma?
resection and chemo for teratoma; seminoma is very XRT sensitive, chemo for positive nodes or residual disease; surgery for residual disease after that
127
90% of nonseminoma mediastinal germ cell tumor have elevations in what two markers? and what is the tx?
beta-HCG and alpha-fetoprotein
Tx: cisplatin-based chemo and XRT; surgery for residual disease
128
Benign tumor of the trachea seen in adults? and in children? malignant is usually what?
adults papilloma; children hemangioma; malignant squamous cell carcinoma
129
What is the most common late complication after tracheal surgery? and early complication?
late - granulation tissue formation
early - laryngeal edema
130
Postintubation stenosis – at stoma site with tracheostomy, at cuff site with ET tube
May be able to treat with ___ or ___ May need resection with end-to-end anastomosis if severe.
serial dilatation or with laser
131
Tracheostomy – needs to be between the 1st and 2nd tracheal rings not >3 rings → risk what?
tracheoinnominate fistula
132
What is the tx for tracheoinnominate fistula?
overinflate balloon to plug hole or stick your finger in hole and depress innominate artery. Resect innominate and place graft. Leave trachea alone. Use new tracheostomy site
133
■ Tracheoesophageal fistula: • Use large-volume cuff below fistula • May need decompressing gastrostomy • Tx: tracheal resection, reanastomosis, ___ flap
sternohyoid
134
Lung abscess are most commonly associated with what?
aspiration
135
Tx for lung abscess is abx which are 95% successful, what next if abx fails? and if that fails?
CT guided drainage
surgery if fails or cannot rule out CA (>6 cm, failure to resolve after 6 weeks)
136
What are the three phases of empyema seen in 1-3 weeks respectively?
Exudative phase - 1st week
Fibroproliferative phase - 2nd week
Organized phase - 3rd week
137
What is the tx of empyema during the 1st and 2nd weeks? and 3rd week (3 options)?
abx and chest tube in 1st and 2nd week
3rd week - Tx: likely need decortication; fibrous peel occurs around lung • May need Eloesser flap (direct opening to external environment) for chronic unresolving empyema • Can also place a chronic chest tube that is gradually pulled out
138
50% of chylothorax is secondary to what cause? and the other 50%
50% secondary to tumor, 50% secondary to trauma or iatrogenic injury
139
What is the most common tumor to cause chylothorax?
lymphoma due to tumor burden on lymphatics
140
The thoracic duct runs along the right side and dumps into the left sublavian vein at junction with internal jugular. Where does it cross? Why is this location significant in chylothorax?
T4-5
Injury above T5–6 results in left-sided chylothorax ■ Injury below T5–6 results in right-sided chylothorax
141
Tx for chylothorax is 3-4 weeks of conservative therapy * chest tube, octreotide, low-fat diet or TPN). What if that fails for chylothorax secondary to trauma or iatrogenic injury? and for malignant cases?
If that fails, surgery with ligation of thoracic duct on right side low in mediastinum (80% successful) if chylothorax secondary to trauma or iatrogenic injury
For malignant causes of chylothorax, can perform mechanical or talc pleurodesis (less successful than above)
142
What stain can be used to stain fat in chylothorax?
sudan red stain
143
Does the milky white fluid in chylothorax that is high in lymphocytes and TAGs get infected?
chylothorax is fluid resistant to infection
144
Massive hemoptysis (>600 cc/24 h), bleeding is from high pressure bronchial arteries. Most commonly secondary to infection. What type is most common?
mycetoma (fungal)
145
What is the tx for massive hemoptysis (>600cc in 24 hrs)?
place bleeding side down if know; rigid bronchoscopy to identify site; mainstem intubation to side opposite of bleeding to prevent drowning in blood; to OR for lobectomy or pneumonectomy; brochial artery embolization if not suitable for surgery
146
Spontaneous pneumothorax seen in tall, healthy, thin, young males. Recurrence risk after 1st pneumothorax is what percent? after 2nd? after 3rd?
20%, 60%, 80%
147
Which side is spontaneous pnuemothorax most common?
right
148
What is the tx for spontaneous pneumothorax?
chest tube
149
When is surgery indicated for spontaneous pneumothorax?
recurrence, large blebs on CT scan, air leak >7 days, nonreexpansion.
Also need surgery for high-risk profession (airline pilot, diver, mountain climber) or pts who live in remote areas
150
What is the most common cysts of the mediastinum and their usual location?
bronchiogenic cysts, usually posterior to the carina
151
What type of pneumothorax occurs in temporal relation to menstruation. Caused by endometrial implants in visceral lung pleura?
catamenial pneumothorax
152
Residual hemothorax despite 2 good chest tubes. What next?
OR for thorascopic drainage
153
Clotted hemothorax - surgical drainage if >25% of lung, air-fluid levels, or signs of infection; surgery in 1st week to avoid what?
avoid peel
154
Whiteout on CXR:
Midline shift toward whiteout is most likely collapse. Needs what tx?
No shift - do CT to figure it out
Midline shift away from whiteout likely effusion. Needs what tx?
collapse needs bronchoscopy to remove plug
effusion needs chest tube
155
Bronchiectasis is acquired from infection, tumor or what other condition?
cystic fibrosis
156
Noncaseating granulomas are seen in what lung condition?
sarcoidosis
157
What is the pleural fluid protein to serum ratio seen in an exudate? and the pleural fluid LDH to serum ratio seen in exudate?
> 0.5
> 0.6
158
Recurrent pleural effusions can be treated with what?
mechanical pleurodesis (talc pleurodesis for malignant pleural effusions)
159
Airway fires are usually associated with the laser. What is the tx?
stop gas flow, remove ET tube, reintubate for 24 hrs; bronchoscopy
160
AVMs, connections between the pulmonary arteries and pulmonary veins; usually occurs in the lower lobes and in pts with what disease?
Osler-Weber-Rendu disease
161
What is the tx for AVMs in the lung?
embolization
162
What is the most common benign chest wall tumor? and malignant?
benign - osteochondroma
| malignant - chondrosarcoma
