Breast and Endocrine Surgery Flashcards
A 43 year old lady is diagnosed as having a malignant lesion in the inferior aspect of her left breast. There is palpable axillary lymphadenopathy. What is the most appropriate course of action?
Mastectomy and axillary node clearance Wide local excision and axillary node clearance Wide local excision and sentinel lymph node biopsy Image guided fine needle aspiration of the axillary nodes CT scanning of the chest, abdomen and pelvis
Image guided fine needle aspiration of the axillary nodes
Where axillary nodal involvement is suspected from the outset it is important to establish whether this is the case prior to surgery. This is because, if axillary metastatic disease is present then the correct management would be an axillary node clearance and this is irrespective of the surgical plans for the breast primary. In the case of breast cancer, image guided FNAC is acceptable as it is accurate and if carcinoma cells are identified at FNA then axillary node clearance can be performed. If FNAC is negative then a sentinel node biopsy should accompany excision of the primary tumour.
A 44 year old lady presents with a mass lesion in the upper outer quadrant of the left breast. On clinical examination she has a 2cm mass lesion which on core biopsy is demonstrated to have invasive ductal carcinoma. An FNA of a bulky axillary lymph node contains malignant cells. What is the correct course of action?
Wide local excision and axillary node clearance Radical mastectomy and axillary node clearance Simple mastectomy and sentinel node biopsy Wide local excision and sentinel node biopsy Excision biopsy and sentinel node biopsy
Wide local excision and axillary node clearance
Although the primary lesion is small enough for breast conserving surgery, the presence of overt axillary lymph node metastasis will attract a recommendation for axillary node clearance. Note that an excision biopsy is not appropriate for malignant cases.
A 43 year old lady has recently undergone a wide local excision and sentinel lymph node biopsy for carcinoma of the breast. Of the factors listed below, which will provide the most important prognostic information?
Mitotic number Grade Nodal status Size Oestrogen receptor status
Nodal status is the single most important prognostic factor in breast cancer.
A 53 year old lady has recently entered the UK from the far East and she undergoes a thyroidectomy for a very large multinodular goitre with retrosternal extension. The operation is relatively straightforward otherwise. The patient is returned to the recovery area and suddenly becomes profoundly dyspnoeic and hypoxic. On examination, the wound is healthy and dry and the drain empty. What is the most likely cause?
Contained haematoma Unilateral recurrent laryngeal nerve injury Unilateral superior laryngeal nerve injury Tracheomalacia Hypocalcaemia
With long standing very large goitre, there is a risk of tracheomalacia. In the UK this is very rarely seen. However, patients from other countries can have enourmous goitres and this then becomes a concern. The fact that the wound is satisfactory makes a bleed less likely and whilst total thyroidectomy can be a risk factor for hypocalcaemia, this is a little early.
A 45 year old lady presented with a 2cm mobile breast mass. A mammogram is indeterminate (M3), USS shows benign changes (U2), clinical examination is also indeterminate (P3). What is the next most appropriate course of action?
Re-assure and discharge Fine needle aspiration cytology Excision biopsy Image guided core biopsy Wide local excision
Image guided core biopsy
All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed.
A 27 year old lady presents with a breast lump. She has previously undergone a breast augmentation with an implant. Which of these imaging techniques is the most appropriate next step?
Ultrasound CT scanning MRI PET CT Mammography
Unless there are concerns about implant rupture, the imaging of a breast lump in a young patient with implants would be USS initially. If this is not conclusive then MRI should be performed.
A 52 year old woman with known Hashimotos thyroiditis presents with a neck swelling. She describes it as rapidly increasing in size over 3 months and she complains of dysphagia to solids. On examination, there is an asymmetrical swelling of the thyroid gland. What is the most likely diagnosis?
Anaplastic thyroid cancer Follicular thyroid cancer Papillary thyroid cancer Lymphoma Toxic adenoma
Thyroid lymphoma (Non Hodgkin’s B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto’s thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option
A 34 year old female presents with a thyroid nodule. She has a family history of thyroid disease and both her sisters have undergone total thyroidectomies. Her past medical history includes hypertension which has been difficult to manage. What is the most likely underlying thyroid lesion?
Papillary thyroid cancer Follicular adenoma Medullary thyroid cancer Anaplastic thyroid cancer Lymphoma of the thyroid
This is a typical scenario for medullary carcinoma in which a phaeochromocytoma may also be present. It may be inherited in an autosomal dominant fashion and affected family members may be offered prophylactic thyroidectomy.
A 56 year old woman has undergone a wide local excision and axillary node sample. The histology shows a 2.5cm invasive ductal carcinoma grade 1 which is completely excised. None of the axillary lymph nodes show evidence of metastatic disease. What is the most appropriate course of action?
Arrange routine surgical follow up Completion mastectomy Radiotherapy to breast and axilla Administration of tamoxifen Radiotherapy to breast alone
This woman has a good prognosis. However, irradiation of the breast is mandatory after breast cancer has been treated using breast conserving surgery. Note that only the breast needs to be irradiated in this case and not the axilla.
A 20 year old lady presents with a lump in the upper outer aspect of her right breast. On examination, she has a firm mobile mass in the upper outer quadrant of her right breast. What is the most likely underlying disease process?
Atypical ductal hyperplasia Breast cyst Duct ectasia Fibroadenoma Fat necrosis
Fibroadenomas account for 60% of discrete breast lesions in the 18-25 year age group. They are mobile lesions. Core biopsy should be performed in lesions measuring more than 4cm in diameter.
A 52 year old woman presents with an acutely ischaemic right arm. She is found to have fast atrial fibrillation. Her blood results reveal a free T4 level of 20 and a TSH of < 0.01. What is the most likely diagnosis?
Poor compliance with thyroid medication Thyrotoxicosis Multinodular goitre Sick euthyroid syndrome Hashimotos thyroiditis
The diagnosis is thyrotoxicosis. An elevated T4 and a low TSH should indicate this diagnosis. Remember atrial fibrillation and its complications i.e acute ischaemic limbs can be precipitated by hyperthyroid disorders
A 70 year old lady with metastatic breast cancer is admitted to hospital confused and acutely unwell, with nausea and vomiting. Her vital signs are within normal limits. What abnormality is most likely to contribute to her clinical condition?
Hyponatraemia Hypernatraemia Hypocalcaemia Hypercalcaemia Hyperkalaemia
The commonest site of metastatic breast cancer is to a bony site (often the axial skeleton) and so hypercalcaemia is often present in those with metastatic disease who are acutely unwell.
A 63 year old man is recovering following a protracted stay on the intensive care unit recovering from an anastomotic leak following a difficult trans hiatal oesophagectomy. His progress is slow, and the intensive care doctors receive the following thyroid function test results:
TSH 1.0 mU/L
Free T4 8 micrograms/ dl (normal 4-11)
T3 1.0 micrograms/ dl (1.2-3.1 normal)
What is the most likely interpretation of these results and findings?
Hyperthyroidism Anxiety state Sick euthyroid Normal euthyroid Hypothyroidism
Sick euthyroid syndrome is caused by systemic illness. With this, the patient may have an apparently low total and free T4 and T3, with a normal or low TSH. Note that the levels are only mildly below normal.
A 29 year old man presents to the clinic with a recurrent thyroid cyst. It has been drained now on three occasions. Each time the cyst is aspirated and cytology is reassuring. What is the most appropriate course of action?
Reassure and discharge Resection of the ipsilateral thyroid lobe Enucleation of the cyst Total thyroidectomy Radio-isotope scan
Resection of the ipsilateral thyroid lobe
Persistently refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy.
An 82 year old woman from a nursing home is admitted to the orthopaedic ward with a hip fracture. She is acutely confused and agitated. Her Calcium is 2.95 (elevated) and her PTH is 12 (elevated). What is the best course of action?
Administration of intravenous dextrose Administration of intravenous crystalloid Sestamibi scan Administration of intravenous colloid Emergency parathyroidectomy
Administration of intravenous crystalloid
Whilst she may have an underlying parathyroid lesion, resuscitation should occur first. Initially, this should be with crystalloid.
A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least likely to be the cause of his symptoms?
Spironolactone Carbimazole Chlorpromazine Cimetidine Methyldopa
Carbimazole
Carbimazole is not associated with gynaecomastia. Note the question asks for the least likely cause.
A 72 year old female is found to have a malignant lesion in her left arm. She had a mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left arm. What is the most likely cause of the malignancy?
Lymphangiosarcoma Lymphoma Myeloma Angiomyolipoma Giant cell tumour
Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy.
A 39 year old lady presents with a mass lesion in her right breast. Clinical examination, biopsy and imaging confirm a 2.5 cm lesion in the upper inner quadrant of her right breast and a 1.5 cm lesion at the central aspect of the same breast. Her axilla shows lymphadenopathy and a fine needle aspirate from the node shows malignant cells. What is the best course of action?
Simple mastectomy and axillary node clearance Wide local excisions of the two lesions and axillary node clearance Simple mastectomy and sentinel node biopsy Wide local excisions of the two lesions and sentinel node biopsy Radical mastectomy and axillary node clearance
Simple mastectomy and axillary node clearance
A combination of established axillary disease and multifocal invasive lesions attracts an indication for mastectomy and axillary clearance. A radical mastectomy is less frequently indicated in modern surgical practice
A 55 year old woman presents with nipple discharge. On examination, she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast. Which of the factors listed below is most strongly associated with developing this condition?
BRCA 1 positivity Smoking Alcoholism Obesity Type II diabetes mellitus
Smoking is a major risk factor for duct ectasia
A 56 year old man is investigated with an abdominal CT scan for a change of bowel habit towards constipation. It shows no colonic lesions. However, a right sided adrenal lesion is noted and measures 2.5cm in diameter. What is the most appropriate course of action?
Arrange an MRI of the adrenal gland Arrange an adrenal USS Arrange an image guided core biopsy Undertake an adrenalectomy Arrange a hormonal assay
Arrange a hormonal assay
The vast majority of small adrenal lesions are incidental, benign and non functioning adenomas. Apart from minimal workup, no further investigation is needed. Of note, if there are concerns about malignancy, the only surgical option is adrenalectomy.
A 59 year old man is referred with symptoms of dysphagia. On examination, he has a large goitre and on imaging there is significant retrosternal extension and features of a multinodular goitre. What is the most appropriate course of action?
Total thyroidectomy Sub total thyroidectomy Thyroid lobectomy Radio-iodine Conservative management
Total thyroidectomy
Sub total thyroidectomy is no longer routinely undertaken in this group.
A 58 year old male is referred to endocrinology clinic for a parathyroidectomy by the F1 in medicine. His corrected calcium is 2.85 (2.2-2.6), PTH 7.5 (3-7) and 24 hour urinary calcium is 1.5 (2.5-7.5). What is the diagnosis?
Primary hyperparathyroidism Secondary hyperparathyroidism Tertiary hyperparathyroidism Familial hypocalciuric hypercalcaemia Hypercalacemia associated with malignancy
This F1 should have spoken to his senior. This patient has familial hypocalciuric hypercalcaemia, which requires no further action. A calcium to creatinine clearance ratio of <0.01 will confirm this diagnosis.
A 19 year old lady is admitted to ITU with severe meningococcal sepsis. She is on maximal inotropic support and a CT scan of her chest and abdomen is performed. The adrenal glands show evidence of diffuse haemorrhage. What is the most likely explanation?
Waterhouse- Friderichsen syndrome Nelsons syndrome Walker - Warburg syndrome Spontaneous bleed into a malignant lesion Spontaneous bleed into a cyst
Waterhouse - Friderichsen syndrome is defined as adrenal gland failure due to bleeding into the adrenal glands. It is caused by severe bacterial infection (most commonly the meningococcus Neisseria meningitidis).
A 50 year old lady is commenced on tamoxifen for the treatment of an oestrogen receptor positive breast cancer. Which of the following malignancies are associated with tamoxifen use?
Adenocarcinoma of the colon Hodgkins lymphoma Adenocarcinoma of the lung Ovarian cancer Endometrial cancer
Tamoxifen is an oestrogen receptor antagonist in breast tissues. However, at other sites, such as the endometrium it may act as an agonist. Hence the reason for increasing risk of endometrial cancer.
A 48 year old lady presents with discomfort in the right breast. On examination, she has a discrete, soft, fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a halo sign is seen by the radiologist. What is the most likely explanation for this process?
Breast cyst Fibroadenoma Radial scar Atypical ductal hyperplasia Ductal carcinoma in situ
Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic, these cysts should be aspirated.
Which investigation is best for initial assessment of recurrence of follicular carcinoma of the thyroid?
Free T4 Thyroid stimulating hormone Scintigraphy Serum thyroglobulin USS thyroid gland
Elevated thyroglobulin levels raises suspicion of recurrence.
