Breast and Endocrine Flashcards
What does ANDI stand for?
Abnormalities of normal development and involution
4 reproductive phases of a woman’s life
- development
- cyclical change
- pregnancy
- involution
Benign breast issues by age
15-30: fibroadenoma
20s + 30s: mastalgia and lumpiness
30s + 40s: cystic changes
65+: cancer
Object of aspirating a breast cyst
- excluding a solid lesion
- relieve pain
Worrying features after cyst aspiration
- blood stained fluid
- residual mass
(no cytology needed unless blood stained)
Definition of mastalgia
Any pain (tenderness, fullness, aching) felt in the breast
2 types of mastalgia
- cyclical bilateral
- non-cyclical focal
Possible anti-oestrogen meds for severe cases of mastalgia
- danazol 100mg
- tamoxifen 10mg
for 3 months
Treatment of post partum breast infection
Flucloxacillin or erythromycin
Clinical features of periductal mastitis
- retro and peri-areolar inflammation
- oedema
- nipple retraction
Treatment of periductal mastitis
- co-amoxiclav for 2 weeks
What are fibroadenomas?
NOT NEOPLASMS
- fibrous overgrowths of a single lobule
What are giant fibroadenomas?
> 5cm
Clinical features of fibroadenomas
- painless
- well defined
- very mobile
How does treatment of fibroadenoma change with age?
- over 25, need triple testing
- over 35, need histological diagnosis
What is triple testing?
- clinical exam
- cytology
- mammogram/US
Susupicious features of a nipple discharge
- spontaneous
- single duct
- blood stained
- unilateral
What to do if a nipple discharge is suspect
- microdocotomy
Causes of gynaecomastia
Physiological
- neonatal
- puberty
- old age
Drugs
- oestrogen
- digoxin
- steroids
Liver failure
Rare tumours (testes, adrenal)
Risk factors for breast cancer
- female
- advancing age
- family history
- irradiation
- BRCA1/2
- wide ostrogen window
- few/no children
- late birth of first child
- HRT
- OCP
- smoking
Symptoms of breast cancer
- painless lump
- change in appearance
- nipple discharge
- Paget’s
- extramammary mets
Signs of breast cancer
- mammographic lesion
- nipple discharge
- thickened area/ shelving mass
- overlying skin dimpling/ ulceration
- nipple retraction
- visible mass
- fixity to underlying msucle
- skin oedema
- palpable axillary nodes
- supraclavicular glands
- symptomatic mets
Features of breast malignancy on mammogram
- microcalcifications
- density with surrounding spiculation
- distortion of breast architecture
- tethering
Indications for mammography in patients with proven cancer
- to exclude multi-centric/contralat disease
- to exclude DCIS
- follow up
Indications for mammography in patients with clinical problems
- discrete mass in women >30
- vague thickening in women <30
- single nipple discharge
- focal mastalgia
- unexplained nipple retraction
3 categories of primary breast cancers
- non-invasive epithelial cancers (carcinoma in situ)
- invasive epithelial cancers
- mixed connective and epithelial
Most common breast cancer
Infiltrating ductal carcinoma
Met screen in breast cancer
All patients:
- CSR
- LFTs
If LFTs abnormal
- liver US
If >T3
- bone scan
Hormone modifying drugs used in breast cancer
- tamoxifen
- Herceptin
Therapy option in breast cancer
- surgery
- radiotherapy
- chemotherapy
- endocrine manipulation
- biological treatment
Surgical options for breast surgery
- total mastectomy
- wide local excision
Patients suitable for a WLE
- tumour size <5cm, single lesion
- large breast (only 10% should be removed)
- outer quadrants
- no family history
- no multifocal disease
- willing to receive 6 weeks of adjuvant radiotherapy
Options for axillary lymph node surgery
- axillary nodal clearance
- sentinel lymph node biopsy
Patients suitable for sentinel lymph node biopsy
- T1/2
- no palpable lymph nodes
- no prior axillary surgery, irradiation or chemo
How is sentinel node biopsy done?
- want to remove first draining node
- technetium injected around the tumour 24 hours prior
- detected with gamma rays
- node is detected and sent for frozen section
Endocrine manipulation options for pre-menopausal women
- tamoxifen (ER receptor competitor)
- LHRH agonist (Zoladex)
- progesterones
- oopherectomy (rare)
Endocrine manipulation options for post-menopausal women
- aromatase inhibitors
- tamoxifen
- pregesterones
What is a biological modifiers used in breast cancer?
Trastuzumab
- for Her-2-neu positive patients
What is Pagets?
Intraductal carcinoma which invades the skin
- mimics eczema
- always involves the nipple and then moves to areola
- diagnose with punch biopsy
What is inflammatory breast cancer?
- locally advanced carcinoma which mimics cellulitis/ abscess
- red, hot, with rapid course
- dermal lymphatic invasion
- needs aggressive neoadjuvant chemo
Causes of a goitre
- multinodular
- physiological
- throiditis
- thyroid carcinoma
Causes of a solitary nodule
- hyperplastic/adenomatous nodule
- simple cyst
- follicular adenoma
- thryoid carcinoma
Bethesda classification
1 = non- diagnostic 2 = benign 3 = indeterminate 4 = suspicious for follicular neoplasm 5 = suspicious for malignancy 6 = malignant
Modes of investigation for nodular thyromegaly
- US
- apiration cytology
- radio-isotope scanning
- CT scan
US features of thyroid malignancy
- hypoechogenic
- increased vascularity
- local lymphadenopathy
- microcalcification
Tumour marker for thyroid medullary carcinoma
- calcitonin
Features of a malignant thyroid mass
- asymmetrical goiter/ solitary nodule in children/men
- rapid onset
- progressive increase in size
- pain
- local invasion
- lymphadenopathy
- hoarseness
Types of thyroid carcinoma
- well differentiated
- medullary
- anaplastic
- lymphoma
Types of well-differentiated thyroid carcinoma
- papillary
- follicular
- mixed
How does papillary thyroid carcinoma spread?
Lymph node spread
How does follicular thyroid carcinoma spread?
Haematogenous
Components of MEN2 syndrome
- Medullary thyroid carcinoma
- phaeochromocytoma
- hyperparathyroidism
- neurofibromatosis
Common causes of thyrotoxicosis
- Graves disease
- Toxic multinodular goitre (Plummers)
- Toxic solitary nodule (toxic adenoma)
Rare causes of thyrotoxocosis
- Excess TSH (pituitary)
- Excess T4 (iatrogenic)
- Excess iodine (Jod Basedow)
- transient during thyroiditis
Options for the management of thyrotoxicosis
- Neomercazole
- Propanolol
- I131
- surgery
Complications of thyroid surgery
Structural
- laryngeal nerve damage
- laryngeal oedema
- haemorrhage
- thracheomalacia
Endocrine
- hypoparathyroidism
- hypothyroidism
- thyroid crisis
Function of the parathyroid glands
To maintain the body’s calcium and phosphate levels within a very narrow range so that the muscles and nerves can function properly
Hormones that control calcium
PTH increases
Calcitonin decreases
Causes of hypercalcaemia
- disorders of the parathyroid glands
- malignancy
- vit D disorders
- high bone turn over
- renal disorders
Clinical presentation of hypercalcaemia due to hyperparathyroidism
- recurrent renal calculi
- progressive bone density loss
- pathological fractures
- ill-defined musculo-skeletal complaints
- neurocognitive impairment
- unexplained abdo pain
(bones, stones, moans and groans)
How does a hypercalcaemic crisis present?
- rapidly rising calcium levels
- polyuria
- dehyrdration
- confusion, coma, death
Diagnosis of
primary hyperparathyroidism
- elevated serum calcium
- elevated parathyroid hormone
- sestaMIBI scan
- US
Cause of secondary hyperparathyroidism
- chronic renal failure
- GIT malabsorption states
Phosphate retention and calcium deficiency stimulate glands to secrete PTH
Chronically depletes bone calcium stores
Diagnosis of secondary hyperparathyroidism
Normal serum calcium levels
High levels of PTH
Cause of tertiary hyperparathyroidism
Successful renal transplant with ongoing hypercalcaemia
Features suggestive of Zollinger-Ellison Syndrome
- recurrent ulcer
- refractory ulcer
- multiple ulcers
- ulcers in unusual sites
- ulcer and diarrhoea
- ulcer and MEN syndrome
Suggestive features of insulinoma
- hypoglycaemia
- neuroglycopenia
- catecholamine release (sweating, palpitations)
Other name of MEN1
Wermer’s Syndrome
- pituitary
- pancreas
- hyperparathyroidism
Other name of MEN 2a
Sipple syndrome
- medullary thyroid cancer
- phaeochromocytoma
- hyperparathyroidism
Other name of MEN2b
mucosal neuroma syndrome
- medullary thyroid cancer
- phaeochromocytoma
- marganoid habitus
- mucosal neuromas
Causes of Cushing’s syndrome
- steroids
- pituitary
- ectopic ACTH
- adrenal (Adenoma/carcinoma)
Clinical features of Cushing’s syndrome
- central obesity
- weakness, proximal myopathy
- hypertension
- skin changes
- psych changes
- amenorrhoea/impotence
- osteoporosis
- thirst/ polyuria
- glucose intol
What are phaechromocytomas?
Tumours of the adrenal medulla
- produce adrenalin and noradrenaline
Syndromes that phaeochromocytoma is associated with
- MEN2
- neurofibromatosis
- Von Hippel-Lindau syndrome
Test for phaeochromocytoma
Urinary catecholamine
Features of phaeochromocytoma
- hypertension in the young
- rapidly progressive hypertension
- poorly controlled hypertension
- paroxysmal attacks
Treatment of phaeochromocytoma
- alpha blockade with phenoxybenzamine or prazocin
- removal of the tumour
What is Conn’s syndrome
An aldosterone secreting adenoma of the adrenal cortex
When to suspect Conn’s syndrome
- hypertension
- weakness (from hypokalaemia)
Investigation of Conn’s syndrome
- hypokalaemia and excessive urinary potassium secretion
- excessive aldosterone secretion (blood and urine levels)
- depressed renin levels
- localization of the adenoma by CT scanning
Surgically correctable hypertension
- coarctation of the aorta
- renovascular hypertension
- phaeochromocytoma
- Conn’s syndrome
- Cushing’s syndrome
What is adrenogenital syndrome
Increase in pituitary ACTH production
- adrenocortical hyperplasia
- inappropriate adrenal androgen secretion
What is Addison’s disease
Desctruction of the adrenal gland by:
- TB
- autoimmune adrenalitis
- metastatic disease
- mineralocorticoid and glucocorticoid insufficiency
Symptoms of Addison’s disease
- fatigue
- weight loss
- anorexia
- nausea and vomiting
- abdo pain
- diarrhoea
Management of Addison’s disease
- immediate administration of 4mg dexamethasone
