Breast, endocrine, head and neck Flashcards

Question 1

Q

Reasons for parathyroidectomy in asymptomatic hyperparathyroidism

Answer

A

Age <50

T or Z score 2.5 on DEXA

eGFR <60

Vertebral fractures on radiological evaluation

Renal stones on radiological evaluation

Serum calcium >0.25mmol/L over reference range

Question 2

Q

5 Things to look for on a mammogram

Answer

A

Mass

Calcifications

Architectural distortion

Spiculation

Skin changes

Question 3

Q

Benign breast disease can be best grouped into which three categories

Give an example of each

Answer

A

Non proliferative

Cysts
Papillary apocrine change
Mild hyperplasia of the usual type

Proliferative without atypia

Usual ductal hyperplasia
Intraductal papillomas
- Single or diffuse papillomatosis
Sclerosing adenosis
Radial scars (complex sclerosing lesions)
Fibroadenomas

Proliferative with atypia

Atypical ductal hyperplasia
Atypical lobular hyperplasia
Lobular carcinoma in situ
Flat epithelial atypia

Question 4

Q

Benign proliferative breast lesions with atypia

Answer

A

Atypical hyperplasia

Atypical ductal hyperplasia (ADH)
Atypical lobular hyperplasia (ALH)

Lobular carcinoma in situ (LCIS)

Flat epithelial atypia (FEA)

No increase in cancer risk

Question 5

Q

Hypertrophy

Answer

A

Enlargement of individual cells

Question 6

Q

Hyperplasia

Answer

A

Increase in number of cells

Question 7

Q

MEN1

Answer

A

Autosomal dominant

Rare

Clinically defined as either:

The occurence of 2 or more MEN1 tumour types
1 MEN1 tumour type with a family history of clinical MEN1

Defects in the MEN1 gene

Encodes menin

Three main effects

Primary hyperparathyroidism
Pituitary adenomas
Pancreatic NETs
- Gastrinoma (ZES) most common
- Both functional and non functional

Other associations

Thymic carcinoid (non functional)
Collaginomas
Adrenocortical nodular hyperplasia
Lipomas
Angiofibromas

Question 8

Q

MEN2

Answer

A

Rare

Autosomal dominant

Defects in RET proto-oncogene on chromosome 10

Subclassified in MEN2A and MEN2B

Both develop:

Medullary thyroid cancer
Phaeochromocytoma

MEN2A only

Hyperparathyroidism

Question 9

Q

What percentage of breast cancers are hormone receptor positive

Question 10

Q

As a general rule what is the benefit to survival with 5 years of Tamoxifen

Answer

A

Reduces the risk of death by around 1/3 (RR 0.7) during treatment, and

this effect continues for years 5-9

Question 11

Q

What is the role for Ovarian suppression in breast cancer

Answer

A

Adjuvant therapy

Improves survival in premenopausal women who also require chemotherapy

especially in early age

Goserelin is the most studied agent

Side effects are significant
- Hot flushes
- Hypertension
- MSK symptoms
- Depression

Question 12

Q

What are the 2 main side effects of Tamoxifen

Answer

A

VTE

Uterine carcinoma

Question 13

Q

Monitoring bone loss in aromatase inhibitor use

How is this treated

Answer

A

Dexa scan every 2 years

Treatment with bisphosphonates

Question 14

Q

What is the rate of Amenorrhoea after chemotherapy in breast cancer,

What should be offered to premenopausal women who may require chemotherapy

Answer

A

50%

Fertility consultation and egg banking

Goserelin may reduce this risk significantly

Question 15

Q

What improvement in recurrence of breast cancer does chemotherapy generally offer

Answer

A

25% annual risk reduction

This holds true for most situations
- High risk disease simply has a greater benefit as a function of the higher recurrence rates

Question 16

Q

What do the AJCC grading guidelines classify as chest wall invasion

Answer

A

The chest wall includes ribs, intercostal muscles, and serratus anterior muscle, but not the pectoral muscles.

Therefore, involvement of the pectoral muscle in the absence of invasion of these chest wall structures or skin does not constitute chest wall invasion

such cancers are categorized on the basis of tumor size

Question 17

Q

Usual lymphatic drainage of the breast.

What sites are considered regional vs metastatic disease in breast cancer

Answer

A

The breast lymphatics drain by way of three major routes:

axillary
interpectoral
internal mammary.

Intramammary lymph nodes reside within breast tissue and are designated as axillary lymph nodes for staging purposes.

Supraclavicular lymph nodes are categorized as regional lymph nodes for staging purposes.

Metastases to any other lymph nodes, including cervical or contralateral internal mammary or contralateral axillary lymph nodes, are classified as distant metastases

Question 18

Q

Axillary (ipsilateral): interpectoral (Rotter’s) nodes and lymph nodes along the axillary vein and its tributaries may be divided into the following levels:

Answer

A

Level I (low-axilla):

lymph nodes lateral to the lateral border of pectoralis minor muscle.

Level II (mid-axilla):

lymph nodes between the medial and lateral borders of the pectoralis minor muscle
interpectoral (Rotter’s) lymph nodes.

Level III (apical axilla):

lymph nodes medial to the medial margin of the pectoralis minor muscle and inferior to the clavicle.
- also known as apical or infraclavicular nodes.
- Metastases to these nodes portend a worse prognosis.
  - the infraclavicular designation should be used to differentiate these nodes from the remaining (Level I, II) axillary nodes.
  - Level III infraclavicular nodes should be separately identified by the surgeon for microscopic evaluation.

Question 19

Q

Where are the internal mammary nodes

Answer

A

Intercostal spaces along the edge of the sternum in the endo- thoracic fascia.

Question 20

Q

How are supraclavicular lymph nodes defined anatomically.

Answer

A

Lymph nodes in the supraclavicular fossa

triangle defined by the omohyoid muscle and tendon (lateral and superior border),
internal jugular vein (medial border)
clavicle and subclavian vein (lower border).

Adjacent lymph nodes outside of this triangle are considered to be lower cervical nodes (M1).

Question 21

Q

To which organs does breast cancer metastasize

Answer

A

The four most common sites of involvement are

bone
lung
brain
liver

breast cancers also are capable of metastasizing to many other sites

Question 22

Q

Breast cancer staging:

T1

Question 23

Q

Breast cancer staging:

T2 and T3 disease

Answer

A

T2

2-5cm

T3

>5cm (not invading chest wall or skin)

Question 24

Q

Breast cancer staging:

T4a and T4b disease

Question 25

Q

Breast cancer staging:

T4b and T4c disease

Question 26

Q

Breast cancer staging:

Inflamatory breast cancer, T staging chacteristics

Answer

A

Inflammatory carcinoma is a clinical-pathological entity characterized by diffuse erythema and edema (peau d’orange) involving approximately a third or more of the skin of the breast.

The tumor of inflammatory carcinoma is classified cT4d.

It is important to remember that inflammatory carcinoma is primarily a clinical diagnosis.

Question 27

Q

Breast cancer staging:

Clinical node staging

Question 28

Q

Breast cancer staging:

Nodal staging:

Macrometastasis vs Micrometastasis vs Isolated tumour cell deposits

Answer

A

Macrometastasis

>2mm

MIcrometastasis

0.2-2mm

Isolated tumour cell deposits

<0.2mm

Question 29

Q

Breast cancer staging:

Nodal status

Axillary only disease

Question 30

Q

Breast cancer staging:

alphabetical suffixes used for extra axillary nodal disease

Answer

A

Internal Mammary

Receives suffix b modifier with or without axillary disease

Supraclavicular

Receives suffix c modifier with or without axillary disease

Question 31

Q

Nonmetastatic breast cancer is broadly considered into which two categories

Answer

A

Early stage

This includes patients with stage I, IIA, or a subset of stage IIB disease (T2N1).

Locally advanced

This includes a subset of patients with stage IIB disease (T3N0) and patients with stage IIIA to IIIC disease.

Question 32

Q

Luminal A type breast cancers

Answer

A

Usually

low-grade
invasive ductal carcinomas (NST) or;
special types of carcinoma
- tubular
- cribriform
- mucinous

Excellent prognosis.

Generally have a poor response to traditional chemotherapy but have an excellent response to endocrine therapies

Question 33

Q

Luminal B type breast cancers

Answer

A

tend to be:

poorly differentiated
Low receptor positivity

less likely to respond to endocrine therapy

more likely to respond to traditional chemotherapy

Question 34

Q

Overview of subtypes of breast cancer

Question 35

Q

What are the parameters for the 8th edition AJCC staging for breast

Answer

A

T stage

N stage

M stage

Grade

HER2status

ER status

PR status

Question 36

Q

Who should receive adjuvant chemotherapy in breast cancer“

Answer

A

Patients who are at an increased risk of local and distant recurrence

Considerations in this decision include

Age- Young age get better improvement
- Likely due to tumour characteristics rather than age per se
Node positive disease
Size (>2cm)
grade (3)
ER/PR status
HER2 Status
High risk genomics/multigene analysis testing (Prosigna)

Question 37

Q

Who should get Herceptin

Answer

A

HER2 + cancers >1cm

Smaller tumours remain controversial

Question 38

Q

Special considerations in the treatment of breast cancer

Answer

A

Fertility preservation

Consider and offer in all premenopausal women

Reconstruction/symmetrization

Multidisciplinary meeting

BRCA status and prophylactic surgery

Psychosocial support

Question 39

Q

Histology of invasive lobular breast cancer

Answer

A

Small cells that insidiously infiltrate the mammary stroma and adipose tissue individually and in a single-file pattern.

E- Cadherin positive

Question 40

Q

Histology of invasive ductal carcinoma

Answer

A

Malignant cells arranged in cords and nests with varying amounts of gland formation

Question 41

Q

What are the standard indications for systemic staging investigations in breast cancer

Answer

A

Locally advanced
- T3 or greater
- N2 or N3
Inflammatory breast cancer
Signs or symptoms suspicious for metastatic disease
Recurrent disease

Question 42

Q

Phyllodes tumors

Answer

A

uncommon fibroepithelial breast tumors

Present as large (>3 cm), rapidly growing breast mass that is usually palpable
- Imaging features of a phyllodes tumor can be suggestive of fibroadenoma
  - Large size and rapid growth differentiate this

capable of a diverse range of biologic behaviors

Least agressive forms behave like benign fibroadenomas,
- although with a propensity to recur locally following excision without wide margins.
More aggressive forms can metastasize distantly
- degenerate histologically into sarcomatous lesions

leaf-like on histology

describes the typical papillary projections that are seen on pathologic examination

Question 43

Q

Breast core biopsy diagnosis of “cellular fibroadenoma,” “cellular fibroepithelial lesion,” or “fibroepithelial lesion with cellular stroma” may suggest which diagnosis?

Answer

A

Phyllodes tumour

Excision biopsy should be performed

Question 44

Q

What features are used to identify benign vs malignant phyllodes tumours

Answer

A

Histologically, phyllodes tumors are classified as benign, borderline, or malignant based upon the assessment of four features:

Mitotic activity
Margins- infiltrative or circumscribed
Stromal overgrowth (ie, presence of pure stroma devoid of epithelium)
Degree of cellular atypia

Question 45

Q

How is grade assessed in breast cancer

Answer

A

By the Nottingham system (Modified Bloom-Richardson-Elston)

3 Point system, each scored 1-3
- Tubule formation
- Mitotic count
- Nuclear pleomorphism
Grade 1
- 3- 5
Grade 2
- 6-7
Grade 3
- 8-9

Question 46

Q

Cernea classification

Answer

A

Of the relationship of the superior lanyngeal nerve to the superior pole of the thyroid

I
- Nerve crosses the superior thyroid vessels >1cm above superior thyroid pole
IIa
- Nerve crosses the superior thyroid vessels <1cm above superior thyroid pole
IIb
- Nerve crosses at or below the superior thyroid pole

Question 47

Q

What are the epithelial derived thyroid cancers

Answer

A

Differentiated

Papillary (85%)
Follicular (12%)

Undifferentiated

Anaplastic (<3%)

Question 48

Q

Staging investigations in differentiated thyroid cancer

Answer

A

Ultrasound

Size
Local invasion
Central and lateral neck nodes

Preoperative laryngoscopy

CT chest and neck for signs or symptoms of locally advanced disease

Dysphagia
Resp compromise
Haemoptysis
Rapid tumour growth
Voice changes
vocal cord paralysis
tumour fixed to surrounding structures
Exthyroidal extension on USS

Consider MRI for operative planning if local invasion suspected

Question 49

Q

Signs and symptoms of locally advanced thyroid disease

Answer

A

Dysphagia

Respiratory compromise

Haemoptysis

Rapid tumour growth

Voice changes

Vocal cord paralysis

Tumour fixed to surrounding structures

Exthyroidal extension on USS

Question 50

Q

Specific risk of thyroidectomy

Answer

A

Nerves

RLN injury
SLN injury

Endocrine

Hypothyroidism and life long replacement
Parathyroid injury
- Transient
- Permanent

Airway

Bleed, oedema, obstruction

Thoracic duct injury

Esp. in large goitres

Question 51

Q

Choice of surgery in differentiated thyroid cancer

Answer

A

Tumor <1 cm without extrathyroidal extension and no lymph nodes –

thyroid lobectomy preferred unless there are clear indications to remove the contralateral lobe

Tumor 1 to 4 cm without extrathyroidal extension and no lymph nodes –

Either a total thyroidectomy or thyroid lobectomy
- Patient preference
- contralateral abnormality
- RAI

Tumor ≥4 cm, extrathyroidal extension, or metastases –

Total thyroidectomy

Radiation exposure

Total thyroidectomy

Question 52

Q

What is the appropriate starting dose for thyroxine post total thyroidectomy

Answer

A

1.6-2mcg/kg/day

Question 53

Q

Hypocalcaemia

Causes and effects

Answer

A

Most commonly induced after parathyroid and thyroid surgery

1-2% of total thyroidectomy
Transient but severe hypocalcaemia can result from rapid blood product infusion due to citrate load (esp FFP and platelets)

Impairs transmembrane depolarisation

Results in parasthesias
muscle spasm
- can progress to tetany
Seizures
Cardiac dysfunction
- Prolongation of QT interval

Question 54

Q

Hypocalcaemia management

Answer

A

Replace magnesium first if concurrent defiency; otherwise replacement will be largely futile

Replacement depends on severity:

Severe:

Defined as:
- symptoms
  - carpopedal spasm, tetany, seizures
  - not perioral paraesthesia- this is considered mild
- prolonged QT interval
- cCa <1.9mmol/L
IV Calcium gluconate
- 1-2g (90-180 elemental calcium) in 50ml of 5% dex infused over 10-20 minutes
  - then slow infusion ~50mg elemental calcium/hour until adequate oral replacement established

Mild

defined as:
- 1.9-2mmol/L
- symptomatic with mild paraesthesia only
oral replacement
- 1500 -2000mg elemental calcium per day in divided doses
  - elemental comprises 40% of calcium carbonate so 1.25g tab has 500mg
    - 2.5g Calcium Carbonate BD
- vitamin D- cholecalciferol
  - decreases the dose of calcium required
  - esp. needed in Vit D deficiency (which most people in NZ have)

Question 55

Q

How is the extent of neck dissection classified

Answer

A

American Head and Neck Society (AHNS) classification system for standardised nomenclature

uses radical neck dissection as starting point.

Radical neck dissection:

All lymph node levels of the neck, AND
Three non-lymphatic structures
- sternocleidomastoid muscle
- internal jugular vein
- accessory nerve

Selective neck dissection:

Any departure from the number of dissected lymph node levels

Modified radical neck dissection:

Any departure from the number of non-lymphatic structures sacrificed

Extended neck dissection

Any operation extended beyond a radical neck dissection

Question 56

Q

Neck node zones

Question 57

Q

Tissue spaces of the neck:

Prevertebral space

Answer

A

behind prevertebral fascia
descends as far as T3
Important in cervical discitis and abscess

Question 58

Q

Tissue spaces of the neck:

Retropharyngeal space

Answer

A

Extends from base of skull superiorly
- continuous through superior and then posterior mediastinum to level of diaphrag inferiorly
Anterior to prevertebral fascia
Posterior to buccopharyngeal fascia
Infection may pass behind the carotid sheath and present in the posterior triangle

Question 59

Q

Tissue spaces of the neck:

Parapharyngeal space

Answer

A

lateral continuation of retropharyngeal space

bonded laterally to pterygoids and parotid sheath

continuous anteriorly with submandibular space

Question 60

Q

Tissue spaces of the neck:

submandibular space

Answer

A

anterior continuation of parapharyngeal space

bounded:

Inferiorly by investing cervical fascia anchored to hyoid
Superiorly by floor of mouth
Contains mylohyoid muscle and the submandibular and submental glands

Question 61

Q

Ludwigs angina

Answer

A

Characteristically aggressive, rapidly spreading “woody” or brawny cellulitis involving the submandibular space.

Infection begins in the floor of the mouth

Infection is bilateral.

Rapidly spreading cellulitis without lymphatic involvement and generally without abscess formation.

Question 62

Q

What are the triangles of the neck

what are their boundaries

Which of the triangles can be further subdivided

what are boundariesof these subdivisions

Answer

A

Posterior triangle

Posterior aspect of SCM
Anterior aspect of Trapezius
Clavicle

Anterior triangle

Midline
Anterior border of SCM
Mandible

Anterior triangle can be further divided into:

Submental
- Anterior to anterior digastric
Digastric
- Between anterior and posterior bellies of digastric
Carotid
- Between posterior belly of digastric and superior belly of omohyoid
Muscular
- Midline to superior belly of omohyoid

Question 63

Q

AMAROS trial

Answer

A

Lancet Oncology 2014

Randomised multicentre trial

T1-T2 primary breast cancers with no palpable lymphadenopathy and who had SLNB positive disease.
- Randomised to level I+II LN dissection vs Axillary RTx
Shows:
- Non inferiority of RTx alone vs LND in axillary recurrence, overall and disease free survival at 5 years
  - Underpowered as rate of recurrence lower than expected
- Increased lymphoedema in the LND arm

Question 64

Q

ACOSOG Z0011 trial

Answer

A

JAMA 2011

Randomised Multicentre Trial

SLNB with completion axillary clearance vs SLNB alone
- Included women with T1-T2 primary tumour
- Breast conserving surgery with negative margins and clinically node negative disease
Shows that local recurrence rates and survival equivilent between the groups
Main criticism:
- Trial protocol mandated no third (axillary) field radiation but most patients received high tangents which included the axilla without a formal axillay field

Answer 57

A

Radioiodine is administered after thyroidectomy in patients with differentiated thyroid cancer to:

Ablate residual normal thyroid tissue (remnant ablation
Provide adjuvant therapy of subclinical micrometastatic disease
Provide treatment of clinically apparent residual or metastatic thyroid cancer.

Answer 58

A

Cabergoline

Dopamine agonist

Answer 59

A

Papillary thyroid cancer with all of the following present:

Tumor does not have aggressive histology
cN0 or ≤5 pN1 micrometastases (<2 mm in largest dimension)
V0
L0
M0
R0
No I131 uptake outside the thyroid bed on the post-treatment scan, if done

3 additional proposed criteria for low risk disease (not in the original 2009 guidelines)

Intrathyroidal, encapsulated follicular variant of papillary thyroid cancer
Intrathyroidal, well-differentiated follicular thyroid cancer with capsular invasion and no or minimal (<4 foci) vascular invasion
Intrathyroidal, papillary microcarcinoma, unifocal or multifocal, including BRAF V600E mutated

Answer 60

A

Tumor
- microscopic perithyroidal invasion
- aggressive histology
N1 (cervical lymph node metastases)
V1
R1
131I avid metastatic foci in the neck

Two additional proposed criteria not included in the ATA guidelines 2009

Clinical N1 or >5 pathologic N1 with all involved lymph nodes <3 cm in largest dimension
Multifocal papillary thyroid microcarcinoma with extrathyroidal extension and BRAF V600E mutated (if known)

Answer 61

A

Any of the following present:

Macroscopic tumour invasion
M1
R2
Postoperative serum thyroglobulin suggestive of distant metastases

Two proposed additional features not included in the original ATA guidelines 2009

Pathologic N1 with any metastatic lymph node ≥3 cm in largest dimension*
Follicular thyroid cancer with extensive vascular invasion (>4 foci of vascular invasion)

Answer 62

A

Columnar
Tall
Insular
Hobnail
Hürthle
Follicular thyroid cancer

Answer 63

A

Low risk disease

generally does not benefit form RIA

Intermediate risk disease

There is limited evidence of significant benefit
- Large retrospective analyses have shown some survival benefit
- no good RCT’s
RAI generally offered.
- Good indications include
  - R1
  - cN(+)
  - Combinations of
    - Aggressive subtypes
    - age
    - Multifocality
    - V1
    - pN >5 nodes but <3cm

High risk

Should receive RAI

Answer 64

A

follicular thyroid

Endodermal origin
Thyroid arises as a tissue bud at the base of the the tongue at the foramen caecum.
descends into the neck and forms bilobed (left and right) glandular tissue
Distal aspect of the thyroglossal duct may form pyrimidal lobe (off midline) or if patent may form a thyroglossal cyst

C- Cells (calcitonin producing)

Neural crest derived
Fourth pharyngeal pouch
reside in the lateral posterior upper 2/3 of the developed thyroid

Answer 65

A

Failure of descent of some, or all, of the thyroid down the thyroglossal tract into the neck

Thyroid tissue at base of tongue

Some malignant potential but low (~30 case reports)

TSH suppression may reduce the size and remove need for surgical resection

Most will represent complete non descent of the thyroid

always assess the full tract
USS neck
Tc99
consider reimplantation of follicular tissue into SCM

Answer 66

A

Hereditary breast and ovarian cancer genes

BRCA genes encode structurally unrelated tumour suppressor proteins involved in DNA repair and apoptosis

Mutation leads to loss of function

2 genes, 1 and 2

Both normally expressed in breast and ovarian tissue

Both autosomal dominant with high penetrance

Especially early onset of breast cancer

increased incidence of tumors of other organs
- Ovarian (low risk <40)
- fallopian tubes
- prostate
- pancreas

Answer 67

A

Breast

70%

Ovarian

40%

Answer 68

A

Breast

70%

Ovarian

15%

Answer 69

A

BRCA1

BRCA2

Li-Fraumeni

TP53

Peutz-Jeghers

STK11

Cowden (PTEN hamartoma syndrome)

PTEN

Heriditary diffusse gastric cancer syndrome

CDH1

Lynch syndrome

MSH1, MLH1, MSH2, PMS2, EPCAM

PALB2

Answer 70

A

Extended genetic testing panel for women with high familail risk for breast cancer

Increases the sensitivity of testing to a level at which a negative result suggests a decreased risk of breast cancer (i.e drop to group 2)
8 genes included
- ATM
- BRCA1
- BRCA2
- CDH1
- CHEK2
- PALB2
- PTEN
- TP53

Answer 71

A

Gynaecomastia

Benign enlargement of male breast tissue, resulting from a proliferation of the glandular component of the breast. Firm subareolar gland and ductal tissue will be palpable on examination,

Pseudogynaecomastia

Breast enlargement caused by excess adipose tissue

Answer 72

A

Common

Incidence of more than 30%.

Results from relative oestrogen excess or relative testosterone deficiency resulting in a high oestrogen-to-testosterone ratio.

Can occur at any age and may be physiological or pathological

Physiological occurs in newbons, puberty, aging and obesity
Pathological is from environmental exposures, illnesses, and some genetic conditions

Answer 73

A

Newborn period

During puberty

Ageing

Gynaecomastia is more common in men aged over 50, owing to the general decline in testosterone levels and a tendency towards weight gain in later life.

Obesity

In overweight men, breast tissue is stimulated by excess oestrogen resulting from the conversion of testosterone to oestradiol by the enzyme aromatase found in adipose tissue.

Answer 74

A

Gynaecomastia is usually bilateral

10% of cases can involve just one breast
- always consider the possibility of breast cancer in a unilateral presentation.

Answer 75

A

Antiandrogens

finasteride
bicalutamide

Antihypertensives

spironolactone

Antiretrovirals

Hormones

oestrogen
prednisone

H2 receptors blockers

Antipsychotics

many others

Answer 76

A

The Nottingham hospital gynaecomastia pathway provides these guidelines for idiopathic gyanecomastia

Sexual maturation has been reached.
- In cases of idiopathic gynaecomastia in men under the age of 25 then a period of at least 2 years has been allowed for natural resolution
Screening has been undertaken, prior to referral, for endocrinological and drug related causes.
Non-surgical treatments have been tried and have been unsuccessful
BMI as measured by the NHS is between 18 and 25 and has been within this range for year as measured and recorded by the NHS
Confirmed non-smoker
Photographic evidence

Answer 77

A

In patients with physiological gynaecomastia, especially adolescent boys, reassurance can be given that most cases are transitory, with more than 90% resolving within three years.

Answer 78

A

Conservative

most will be transient and resolve spontaneously especially in adolescent males

Medical

Tamoxifen is effective but not licenced for this
- Medical management is associated with a high success rate and avoids surgical intervention, but once fibrosis occurs it is largely ineffective.
  - Tamoxifen 20mg od for 3 months is recommended.
  - Treatment should be stopped after 3 months whether a response is seen or not.

Surgery

Answer 79

A

Appropriate baseline blood tests include:

Liver function
Thyroid function
Renal function.

If normal hormone blood screen

Testosterone
LH
- Luteinising hormone
FSH
- Follicle stimulating hormone
Oestradiol
SHBG
- Sex hormone binding globulin
  - allow estimation of free testosterone
PRL
- prolactin.

Answer 80

A

Dehydroepiandrosterona (DHEA)
- Precursor to testosterone and dihydrotestosterone
Dehydroepiandrosterone Sulfate (DHEA-S)
- (only produced in adrenal (and brain)
  - Useful to rule out gonad origin of sex steroid excess
Testosterone

Answer 81

A

Benign, non proliferative

Distension of the terminal duct lobular unit
- Results from obstruction of the efferent ductule

50-90% of women

most common age 35-50

Often assymptomatic, may cause pain or lump

Can be aspirated for symptomatic management

Answer 82

A

BIRADS 4-5

Thick or complex septation
Presence of a solid component
Absence of posterior wall enhancement

Answer 83

A

BIRADS 2-3

Homogenous low-level internal echoes due to echogenic debris

without:
- solid components
- thick walls
- thick septa
- vascular flow

Answer 84

A

Breast Imaging-Reporting and Data System is a risk assessment and quality assurance tool developed by American College of Radiology that provides a widely accepted lexicon and reporting schema for imaging of the breast.

It applies to mammography, ultrasound, and MRI

Scores are graded 0-6 (inclusive) with an increasing risk of malignancy by increasing BIRADS category

Answer 85

A

Assessment

Incomplete

Management

Recall and or review prior imaging

Malignancy rate

N/A

Answer 86

A

Assessment

Negative

Management

Routine screening/surveillance

Malignancy rate

Essentially 0%

Answer 87

A

Assessment

Benign

Management

Routine screening/surveillance

Malignancy rate

Essentially 0%

Answer 88

A

Assessment

Prrobably benign

Management

Short interval surveillance (6 months)

Malignancy rate

>0 but <2%

Answer 89

A

Assessment

Suspicious
- 4a low suspicion
- 4b moderate suspicion
- 4c high suspicion

Management

Tissue diagnosis

Malignancy rate

4a 2-10%
4b 10-50%
4c 50-95%

Answer 90

A

Assessment

Highly suggestive of malignancy

Management

Tissue diagnosis

Malignancy rate

>95%

Answer 91

A

Assessment

Known biopsy proven malignancy

Management

NA

Malignancy rate

NA

Answer 92

A

Benign non proliferative breast lesion.

Papillary apocrine change is a proliferation of ductal epithelial cells showing apocrine features, characterized by eosinophilic cytoplasm

Answer 93

A

Benign non proliferative lesion

Mild hyperplasia of the usual type is an increase in the number of epithelial cells within a duct that is more than two, but not more than four, cells in depth. The epithelial cells do not cross the lumen of the involved space.

Answer 94

A

Benign proliferative breast lesion without atypia

Usually found as an incidental finding on biopsy of mammographic abnormalities or breast masses, characterized by an increased number of cells within the ductal space. Although the cells vary in size and shape, they retain the cytological features of benign cells.

No additional treatment is needed for ductal hyperplasia.

The risk of subsequent breast cancer in women with usual ductal hyperplasia is small, and chemoprevention is not indicated.

Answer 95

A

Intraductal papillomas consist of a monotonous array of papillary cells that grow from the wall of a cyst into its lumen. Although they are not concerning in and of themselves, they can harbor areas of atypia or ductal carcinoma in situ (DCIS).

16% upgraded to malignancy on excision in a metanalysis
- Newer data suggest in the absence of atypia on biopsy the rate of malignancy is very low and excision may not be necessary.

Answer 96

A

Sclerosing adenosis is a lobular lesion with increased fibrous tissue and interspersed glandular cells.

May present as a mass or a suspicious finding on mammogram.

No treatment is needed

The risk of subsequent breast cancer in this population is small, and chemoprevention is not indicated

Answer 97

A

AKA complex sclerosing lesions

Usually incidental when a mass or radiologic abnormality is removed or biopsied.

Occasionally large enough to be detected by mammography, which cannot reliably differentiate between these lesions and spiculated carcinoma.

Characterized microscopically by a fibroelastic core with radiating ducts and lobules.

Most series show that 8 to 17 percent of surgical specimens at subsequent excision are positive for malignancy

there is some evidence that radial scars may be premalignant lesions that can slowly progress from scar to hyperplasia to carcinoma.

No additional treatment beyond excision is needed for radial scars.

The risk of subsequent cancer after excision is small, and chemoprevention is not indicated.

Answer 98

A

Most common benign tumor of breast

most common between the ages of 15 and 35 years
In 20% of cases, multiple fibroadenomas occur in the same breast or bilaterally.

The etiology of fibroadenomas is not known

hormonal relationship is likely since they persist during the reproductive years, can increase in size during pregnancy or with estrogen therapy, and usually regress after menopause.

Answer 99

A

Benign solid tumors containing glandular as well as fibrous tissue

The risk of subsequent breast cancer is slightly elevated only if the fibroadenoma is complex, if there is adjacent proliferative disease, or if there is a family history of breast cancer.

For the majority of women with simple fibroadenomas, there is no increased risk of developing breast cancer

If a presumed fibroadenoma increases in size or is symptomatic, then excision is mandated to rule out malignant change and confirm the diagnosis

Rapid growth of a lesion raises the suspicion for a phyllodes tumor,
- the true incidence of phyllodes tumor at time of excision is rare (0.8 to 9 percent)
CNB cannot definitively distinguish phyllodes tumours from fibroadenoma

Answer 100

A

Benign proliferative breast lesion with atypia

Includes both of:

Atypical Ductal Hyperplasia (ADH)
Atypical Lobular Hyperplasia (ALH)

Both confer a substantial increase in the risk of subsequent breast cancer (RR 3.7 to 5.3)

both ipsilateral and contralateral
provides evidence of underlying breast abnormalities that predispose to breast cancer
Cumulative incidence of breast cancer over 30 years approaches 35%

Answer 101

A

Yearly mammography and twice-yearly breast exams is appropriate

Avoid risk increasing factors

Stop OCP
Avoid HRT
lifestyle and dietary changes

Primary prevention with the selective estrogen receptor modulators tamoxifen or raloxifene, or an aromatase inhibitor, may be considered in women with AH

benefits and risks must be discussed thoroughly.

The Gail model incorporates atypical proliferative disease into a risk calculation that can be used to identify women who are appropriate candidates for primary prevention of breast cancer

Answer 102

A

The Gail model

parameters are:
- age
- first menstrual period
- first degree relatives with breast cancer
- previous breast biopsy
  - ALH present
- race

lifetime risk of breast cancer >1.7% should be referred to a breast surgeon for consideration of risk reduction medications and other strategies

Answer 103

A

Benign proliferative lesion with atypia

AKA columnar cell change with atypia or columnar cell hyperplasia with atypia.

Typically diagnosed on biopsies done for calcifications found on screening mammograms.

The available data suggest that the risk of local recurrence or progression to invasive cancer is low

Answer 104

A

Benign, usually solitary

Composed of mature fat cells.

Soft, nontender, well-circumscribed masses.

sometimes difficult to distinguish lipomas from other conditions; the diagnosis can be confirmed with a core or excisional biopsy.
- Core biopsies are somewhat problematic for lipomas, as it is difficult to be certain that the diagnosis is concordant, and lipomas should be surgically excised if they cause diagnostic confusion, continue to enlarge, or grow rapidly

There is no increased risk of subsequent breast cancer

Answer 105

A

Benign condition that most commonly occurs as the result of breast trauma or surgical intervention.

Fat necrosis can be confused with a malignancy on physical examination and may mimic malignancy on radiologic studies.

It is sometimes necessary to biopsy these lesions to confirm the diagnosis

No increased risk of malignancy

Answer 106

A

Histologically typical fibroadenoma >10cm

excision is recommended to ensure that a phyllodes tumour is not the diagnosis

Phyllodes tumours have a more cellular stromal component than fibroadenomas

Answer 107

A

Typical fibroadenomas

most common in the upper outer quadrant

ages 10-18

may grow or regress with time

Excision over 5cm is reasonable

Answer 108

A

AKA lymphocytic mastitis or lymphocytic mastopathy

Typically premenopausal women who have longstanding T1DM.

Suspicious breast mass with a dense mammographic pattern.

Core biopsy is recommended for diagnostic confirmation.

Pathology shows dense keloid-like fibrosis and periductal, lobular, or perivascular lymphocytic infiltration

Pathogenesis unknown, possibly autoimmune

histologic features are similar to those seen in other autoimmune diseases

Excision is not necessary

no increased risk of subsequent breast cancer.

Answer 109

A

BI-RADS classification provides a scale that identifies breast tissue density as being in one of four categories

A – almost entirely fatty
B – scattered areas of fibroglandular density
C – heterogeneously dense (may obscure small masses)
D – extremely dense (lowers the sensitivity of mammography)
- “radiologically dense breasts” refers to categories C and D

Breast density is important in two ways

breast density affects imaging reliability
dense breasts are an independant risk factor for breast cancer

Answer 110

A

AKA fibroadenolipoma, lipofibroadenoma, or adenolipoma

Benign varying amounts of glandular, adipose, and fibrous tissue

Present as discrete, encapsulated, painless masses or are found incidentally on screening mammography.

Diagnosis can be difficult with limited tissue

do not have specific diagnostic features.
- Core biopsy insufficient to establish the diagnosis.

Coexisting malignancy can occur, excision is recommended

Answer 111

A

Pure epithelial neoplasms of the breast.

They are distinguished from fibroadenomas by sparse stromal elements.

Divided into two main groups: tubular and lactating adenomas.

Lactating adenomas occur commonly in pregnancy.
- well circumscribed and lobulated.

May require excision because of their size but do not have malignant potential

Answer 112

A

benign inflammatory condition of the breast

presents as periarealar mastititis

almost exclusively seen in smokers

Ducts become obstructed and infected
- Most likely a consequence of tissue hypoxia and injury from nicotine and its derivatives
- Ductal plugging with keratin is seen
- there is some postulation that ductal hyperplasia may contribute

Answer 113

A

Pseudoangiomatous Stromal Hyperplasia

Benign stromal proliferation that simulates a vascular lesion

may present as a mass or thickening on physical examination.
- most common appearance on mammography and ultrasound is a solid, well-defined, noncalcified mass.

Histologic appearance is a pattern of slit-like spaces in the stroma between glandular units

May be confused with mammary angiosarcoma

If any suspicious features on imaging, the diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis, and excisional biopsy should be performed.

if no suspicious imaging characteristics, a diagnosis of PASH at core biopsy is considered sufficient, and surgical excision is not always necessary

There is no increased risk of subsequent breast cancer associated with PASH.

Answer 114

A

Rare

benign well circumscribed breast lesion

Malignant potential is low but excision usually recommended esp over 1.6cm

Answer 115

A

composition:

cystic or completely cystic *: 0 points
spongiform *: 0 points
mixed cystic and solid: 1 point
solid or almost completely solid: 2 points

echogenicity:

anechoic: 0 points
hyper- or isoechoic: 1 point
hypoechoic: 2 points
very hypoechoic: 3 points

shape:

wider than tall: 0 points
taller than wide: 3 points

margin:

smooth: 0 points
ill-defined: 0 points
lobulated/irregular: 2 points
extra-thyroidal extension: 3 points

Any and all findings in the final category are also added to the other four scores.

echogenic foci: (choose one or more)
- none: 0 points
- large comet-tail artifact: 0 points
- macrocalcifications: 1 point
- peripheral/rim calcifications: 2 points
- punctate echogenic foci: 3 points

Answer 116

A

TR1: 0 points

benign

TR2: 2 points

not suspicious

TR3: 3 points

mildly suspicious

TR4: 4-6 points

moderately suspicious

TR5: ≥7 points

highly suspicious

Answer 117

A

TR1:

no FNA required

TR2:

no FNA required

TR3:

≥1.5 cm follow up
≥2.5 cm FNA
follow up:
- 1, 3 and 5 years

TR4:

≥1.0 cm follow up,
≥1.5 cm FNA
follow up:
- 1, 2, 3 and 5 years

TR5:

≥0.5 cm follow up,
≥1.0 cm FNA
annual follow up for up to 5 years

Answer 118

A

The Bethesda system

standardised reporting system for cytopathology of the thyroid gland

Graded 1-6

Provides guidance on risk of malignancy and subsequent management

Answer 119

A

Category

Non diagnostic

Risk

1-4%

Management

Repeat FNA with USS guidance

Answer 120

A

Category

Benign

Risk

0-3%

Management

Clinical follow up

Answer 121

A

Category

Atypia of undetermined significance or
Follicular lesion of undetermined significance

Risk

5-15%

Management

Repeat FNA

Answer 122

A

Category

Follicular Neoplasm or
Suspicious for a follicular neoplasm

Risk

15-30%

Management

Diagnostic surgical lobectomy

Answer 123

A

Category

Suspicious for malignancy

Risk

60-75%

Management

Near total thyroidectomy or surgical lobectomy

Answer 124

A

Category

Malignant

Risk

97-99%

Management

Near total thyroidectomy

Answer 125

A

Most parathyroid glands are ultimately found in a eutopic position.

The upper parathyroid glands

located in a more constant position than the lower glands
typically found at the level of cricoid cartilage
posterior to the thyroid gland, in close proximity (1 to 2 cm) to where the RLN crosses the inferior thyroid artery.

The lower parathyroid glands

often located posterior and inferior to the lower pole of the thyroid gland.
These glands lie anterior to the RLN.

If the parathyroid glands cannot be found in these eutopic positions, ectopic locations should be explored

Answer 126

A

Ectopic superior parathyroid gland exploration should include the tracheoesophageal groove and posterior mediastinum.

Often found in a retroesophageal or parapharyngeal location.

Lower parathyroid glands are found in an ectopic location more frequently than upper parathyroid glands largely because of their longer, more variable embryologic descent.

Sites of ectopic lower parathyroid glands include:

thyrothymic ligament
thymus or perithymic fat
carotid sheath
anterior mediastinum.
Occasionally, an abnormal parathyroid gland may be intrathyroidal.
- In such cases, the gland is typically located in a superficial or subcapsular location and can be easily extracted from surrounding thyroid tissue.
- an ipsilateral partial or complete thyroid lobectomy is required in some cases.

Answer 127

A

BIA ALCL

Breast implant associated anaplastic large cell lymphoma

Answer 128

A

Breast Implant Associated Anaplastic Large Cell Lymphoma

Rare- likely 1 in 1000-10000 women with textured implants
- vastly less common in non textured implants
Peripheral CD-30 T cell derived lymphoma
Relatively indolent course
- Early stage disease has an excellent prognosis
Usual presentation is with a seroma
- ~10 years after placement
  - often diagnosed at revision surgery for the same
  - less common presentation is a solid mass
Likely aetiology is low grade chronic inflammation associated with implant prostheses
Surgical resection of the implant, capsule and any associated mass is probably all that is needed for therapy in early stage disease
- Recurrent or advanced disease (which is rare) should be managed with chemotherapy

Answer 129

A

alcohol

male

smoking

HPV

Answer 130

A

Each cavity space has a seperate staging system

Best defined by local vs locally agressive or distant disease

Local-
- stage I-II
- no nodes
Locally aggressive or distant mets
- Stage III and IV
- 4cm or T4 is a good general rule

Management

local
- single modality
  - RTx, excision etc
Aggressive and distant
- Multimodality
  - modified radical dissection
  - RTx
  - chemo

Answer 131

A

the smaller the gland the more likely to be malignant

Answer 132

A

Most common

Pleomorphic adenoma

Others

Myoepithelioma
Basal cell adenoma
Warthin tumor
Oncocytoma
Lymphadenoma
Cystadenoma
Sialadenoma
Ductal papillomas
Sebaceous adenoma
Canalicular adenoma and other ductal adenomas

Answer 133

A

Most common

mucoepidermoid carcinoma

Others

Adenoid cystic carcinoma
Acinic cell carcinoma
Polymorphous adenocarcinoma
Clear cell carcinoma
Basal cell carcinoma
Intraductal carcinoma
Adenocarcinoma, NOS
Salivary duct carcinoma
Myoepithelial carcinoma
Epithelial-myoepithelial carcinoma
Carcinoma ex pleomorphic adenoma
Secretory carcinoma
Sebaceous adenocarcinoma
Carcinosarcoma
Poorly differentiated carcinoma
Undifferentiated carcinoma
Large cell neuroendocrine carcinoma
Small cell neuroendocrine carcinoma
Lymphoepithelial carcinoma
Squamous cell carcinoma
Oncocytic carcinoma

Answer 134

A

The F’s

Formication
Fistula
Freys syndrome
Facial nerve injury
Flap necrosis
First bite syndrome

Answer 135

A

Superficial parotidectomy and selective anterior neck dissection is indicated in melanoma arising anterior to the line between the tragi
Selective posterior neck dissection without parotid surgery for lesions posterior to the tragi

Answer 136

A

Torus palatinus.

Painless, benign boney protuberance

no surgery required

Answer 137

A

lower lip

due to sun exposure

Answer 138

A

Elderly, dehydrated

staph aureus

rehydration

antibiotics

Answer 139

A

Tracheoarterial fistula!

Put a finger in or overinflate the cuff to compress against the sternum
Take to theatre
- resection of the innominate artery

Answer 140

A

It’s normal position

thymus is the most common site of an ectopic gland

Answer 141

A

Posterior midline oesophageal false diverticulum

Occurs through Killians triangle

bordered by:
- inferior fibres of inferior constrictor (oblique)
- upper fibres of crichopharyngeus

Answer 142

A

angiosarcoma

Answer 143

A

Prognosis is very poor, lesions tend to metastasize early to lung and bone

Treatment is with excision where possible

Taxane based chemotherapy may be used as neoadjuvant, adjuvant or palliative treatment

Answer 144

A

5-8 years

Answer 145

A

Improved local control

Small survival advantage

Answer 146

A

Locally

involved margins

To the axilla

any nodes
T3 tumour
high risk disease which comes close to meeting the threshold for radiotherapy

Answer 147

A

The modified van Nuys prognostic index

variables are
- age
- size
- margin
- pathological classification

MSKCC have an online nomogram with more variables

it may be superior to van Nuys but the jury is out

Answer 148

A

START trial

classic is 50Gy in 25 fractions
higher dose per fraction fewer fractions is now more standard
- Dunedin uses 40.5Gy in 15 fractions

Answer 149

A

radiotherapy increases the baseline risk of any procedure by 1/3

Answer 150

A

Field includes level II nodes

Answer 151

A

within 3 months

ideally 8-12 weeks post operatively

Answer 152

A

An autoimmune hyperthyroidism causes by antibidies to the TSH receptor which simulate the effects of TSH

Assays are available and can be used in patients in whom the underlying aetiology is not clear as the most recent assays have very high sensitivity and specificity (TRAb assay)

Answer 153

A

TSH suppression can be achieved by administration of thyroxine

the aim is to achieve low normal TSH levels in patients with an increased risk of recurrence

There does not appear to be a long term benefit beyond 5 years

Answer 154

A

OBS techniques are classified into “level I” and “level II” procedures.

Level I is performed when less than 20% of breast volume is to be excised.
- tissue displacement techniques are performed to repair the defect, and the nipple-areola complex (NAC) is repositioned if required.
Level II techniques are used where resection of 20%–50% of the breast volume is required.
- Many techniques exist
- involves extensive skin resection with a variety of volume displacement or replacement methods.
  - local tissue displacement and glandular reshaping methods are used to fill defects
    - eg, round-block, omega, vertical, radial, V-, J-, and L-type incisions

Answer 155

A

0.4mSv

or ~7 weeks of background radiation

Answer 156

A

Surgery

1cm margin excision
- positive margins are associated with an unacceptable high recurrence rate
  - most markedly in borderline and malignant phyllodes tumours
axillary surgery is not needed

Adjuvant radiotherapy

not indicated for benign
indicated for borderline and malignant

Chemo

no established role
- maybe for very high risk cancers

Hormone

no

Answer 157

A

The majority of patients with benign and borderline phyllodes tumors are cured by surgery.

The survival rate for malignant phyllodes tumors is approximately 60 to 80 percent at five years

Answer 158

A

Chemodectomas

Paragangliomas

Answer 159

A

Paragangliomas are rare neuroendocrine tumors that arise from the extra-adrenal autonomic paraganglia, small organs consisting mainly of neuroendocrine cells that are derived from the embryonic neural crest and have the ability to secrete catecholamines

Answer 160

A

All carotid body tumours should be surgically removed

Although they typically have an indolent course they will eventually progress and may develop vascular or neural invasion which complicates their management

They are easier to remove when small

Answer 161

A

Vascularity

these are highly vascular lesions
- they often encase the external carotid artery
  - rarely the internal
- vascularity is through a rich network in the adventitial plane around the lesion

Nerves

Involvement of the cervical and cranial nerves
- vagus
  - note paragangliomas may also arise here and mimic carotid body tumours
    - glomus intravagale
- recurrent and external laryngeal

Answer 162

A

The axillary vein is identified having incised the clavipectoral fascia along the lateral border of pectoralis major and then by following the latissimus cranially until its tendon is identified.

At the point where the latissimus turns tendinous it is crossed by the axillary vein.
The dissection is done sharply, and accomplishes both the identification of the axillary vein and mobilization of the lateral border of the specimen.
The only important structure that is encountered during this approach is the intercostobrachial nerve, which is usually found one-half to two-thirds of the way to the vein
The fat covering is then divided along the anterior aspect of the vein from lateral to medial
- no major neurovascular structures are encountered across the anterior aspect

Answer 163

A

The thoracodorsal vein is usually the first branch of the axillary vein encountered when dissecting from lateral to medial along the inferior border beginning at the lateral border of latissimus dorsi

the nerve arises deep to the axillary vein and runs medial to the vein
- identification of the vein is the key manoeuvre

Answer 164

A

1400 women of screen age are offered screening

1000 turn up
- 70 are recalled
  - 30 undergo biopsy
    - 24 are benign diagnoses
    - 6 are cancer
      - 2 length time bias
      - 2 lead time bias
      - 2 have improved survival
  - 40 are normal

Answer 165

A

BreastScreen Aotearoa provides a breast screening service for women aged 45 to 69.

Eligible women can have a free mammogram every 2 years to check for breast cancer.

Answer 166

A

2mm

this is based on a large meta-analysis (Ann. Surg. Oncol. 2016) 0f nearly 8000 patients

in some studies 2mm margin effect was removed with radiotherapy

There was no additional protective effect with wider margins

Answer 167

A

Plasma cell mastitis

classically involves more than one breast segment

Answer 168

A

Prolactin

Pituitary adenoma

PTH

Parathyroid adenoma

Gastrin

Gastinoma

Insulin, C peptide and glucose levels

insulinoma

Answer 169

A

Mineralocorticoid hormone

Synthesized in adrenal cortex (glomerulosa) from cholesterol

Increases reabsorption of salt (and hence water) by Na+/K+ and Na+/H+ antiporters.

net effect is loss of potassium and hydrogen and retention of na+ and water.

Release is mediated by angiotensin II

Answer 170

A

C- Cafe au lait

A- Axillary and inguinal freckling

F- Fibromas

E- Eye signs

S- Skeletal- sphenoid winging and long bone dysplasia

P- Phaeochromocytoma

O- Optic gliomas

T- Tumours- sarcomas, nerve sheath tumours

Answer 171

A

moon face

plethora

striae

central obesity

buffalo hump

hirsutism

loss of libido

menstrual irregularity

depression or psychosis

proximal myopathy

easy bruising

Answer 172

A

Often asymptomatic

Stones

nephrolithiasis
also polyuria, thirst
renal failure

Bones

pathological fractures from osteoporosis
z score

Moans

abdominal pain from
- pancreatitis
- PUD
nausea and vomiting

Groans

constipation

Psychiatric undertones

depression
headaches
confusion

Answer 173

A

Tachycardia and AF

Sweating

Facial and palmar flushing

Weight loss

Hair loss

Hyperreflexia

Eye signs

diplopia
exopthalmos
lid lag
lid retraction

Answer 174

A

Cold intolerance

Weight gain

Hyporeflexia

Coarse hair

Bradycardia/Hypotension

Hypothyroid facies

periorbital oedema
loss of the lateral 1/3 of the eyebrows
peaches and cream complexion

Answer 175

A

Grade 0

no visible or palpable goitre

Grade 1

palpable but not visible in the normally positioned neck

Grade 2

visible in the normally positioned neck

Answer 176

A

Comedo

Cribriform

Micropapillary

Papillary

Solid

Answer 177

A

2mm

wider margins do not convey an additional benefit
narrower margins are associated with a 2x increase in recurrence rates

Answer 178

A

Overall 10-20%

in patients presenting with symptomatic DCIS this is closer to 50%

Answer 179

A

Definate:

Mastectomy as the lymphatic drainage will be permanently altered and therefore post operative SLNB will not be possible if maligancy is subsequently recognised in the specimen
- This population is generally at a higher risk of cancer due to larger DCIS area

Relative

Symptomatic disease (50%) rate of malignancy in the specimen
DCIS >5cm
Imaging consistent with malignancy but DCIS on biopsy only

Answer 180

A

By necrosis, subtype and nuclear features.

Low grade
- evenly spaced cells
- small, centrally placed nuclei
- few mitoses
High grade
- pleomorphic irregularly spaced cells
- enlarged nuclei
- frequent mitoses
Intermediate grade
- features between those above

Answer 181

A

1cm deep(medial) and inferior to the tragal pointer

The posterior belly of digastric runs in the same plane as the nerve

the stylomastoid foramen is above the upper margin of that muscle

Tympanomastoid suture line

this is the most precise marker for the facial nerve

Retrograde dissesction

Drill out the mastoid and identify the nerve from within the mastoid bone

Answer 182

A

BRCA 1 and 2 pathogenic variant screening:

individuals with a combined BRCA1 and BRCA2 pathogenic variant probability of ≥10% using a validated pathogenic variant prediction tool
- e.g. CanRisk or Manchester score.
- this may include unaffected individuals and obligate carriers with ≥10% pathogenic variant probability
individuals affected with breast cancer:
- with triple negative pathology diagnosed ≤50 years
- with triple negative breast cancer diagnosed at any age where there is a close relative with breast or ovarian cancer
- diagnosed ≤40 years
individuals with high grade ovarian cancer diagnosed at any age
males affected with prostate cancer who meet prostate cancer panel testing criteria

Pathogenic variant specific BRCA1 or BRCA2 testing:

a pathogenic somatic variant detected on tumour testing for this individual
a personal and/or family history of breast, ovarian, prostate or pancreatic cancer from a population where a common founder pathogenic variant exists (Ashkenazi jews)
a familial BRCA1 or BRCA2 pathogenic variant has been identified

Answer 183

A

50% of people have nodules on USS and autopsy, most are benign.

benign nodules include:
- colloid nodules
- follicular adenomas
- hurthle cell adenomas
- pseudonodules of thyroiditis

Answer 184

A

T1

a
- 0-1cm
b
- 1-2cm

T2

2-4cm

T3

>4cm
invasion into straps only

T4

resectable soft tissues
non-resectable structures
- great vessels
- prevertebral fascia

Answer 185

A

Can almost always be managed with hemithyroidectomy unless there are high risk features

Patient
- radiation
- family history
Tumour
- invasion
- nodes
- mets

Answer 186

A

Papillary cancer- T1b and T2 disease

patients have equivalent survival with total thyroidectomy and with hemithyroidectomy
- decision for total thyoridectomy should be made if there are high risk factors
  - Tumour related
    - contralateral thyroid nodules/multifocality
    - nodal disease
    - high risk subtypes
  - Patient related
    - radiation
    - family history of thyroid cancer
    - patient choice

Answer 187

A

This is T3-4 disease and is managed with total thyroidectomy

other high risk features in addition to size include:
- tumour factors
  - aggressive histologies
  - extrathyroidal extension
  - multifocal disease
  - vascular invasion
  - nodal and distant metastatic disease
- patient factors
  - family history of thyroid cancer
  - radiation exposure

Answer 188

A

Clinical or radiologically apparent lateral nodal disease should undergo FNA to confirm the disease.

selective nodal dissection of levels II,III,IV and VB is warranted

Answer 189

A

Prophylactic considered in

high risk tumours
- associated lateral neck node involvement
- T3/4 disease

Therapeutic

for clinically, radiologically or intraoperatively identified abnormal nodes

Answer 190

A

Thyroid

total thyroidectomy

Nodes

prophylactic bilateral level VI dissection warranted
therapeutic selective lateral dissection in FNA proven disease
the role for prophylactic lateral dissection is debated in patients with high calcitonin levels (>500)
- it is neither recommended for, nor against in the ATA guidelines

Answer 191

A

Anaplastic thyroid cancer is seldom mangaged by surgery as it is so aggressive

it is seldom resectable at presentation

there is occasionally a role for palliative thyroidectomy for local control if there is resectible disease AND it will not delay chemoradiotherapy

Answer 192

A

Use antithyroid medication

PTU in the first trimester
Carbimazole from the second trimester onward

RAI is contraindicated

Surgery is rarely necessary

Answer 193

A

RLN injury

5% transient
1% permanent

Hypoparathyroidism

10-20% transient
1-2% permanent

Post operative bleeding

<1%

Answer 194

A

These include blood and urinary testing

Bloods
- PTH
- Calcium
  - total
  - ionised
- Albumin
- Vitamin D
- Creatinine
- Phosphate
- ALP
Urine- 24 hour collection for:
- volume
- calcium
- creatinine
  - a calcium: creatine of <0.01 is suggestive of Familial Hypercalciuric Hypercalcaemia

Answer 195

A

Familial Hypercalciuric hypercalcaemia is a rare condition

it is only able to be differentiated from hyperparathyroidism by a low urinary calcium
- a calcium:creatinine of <0.01 is indicative
- hyperparathyroidism is characterised by a normal or high urinary calcium

Answer 196

A

Multigene analysis has been studied

BRAF
RAS genes
- KRAS
- NRAS
- HRAS
RET
- RET/PTC1
- RET/PTC3
PAX8/PPARgamma

These have a reported high specificity for thyroid malignancy but a low sensitivity

they may be considered aas a “rule in test” but a negative result does not preclude a malignant diagnosis
- they are therefore not routinely recommended currently

Answer 197

A

The Nottingham Prognostic Index

Calculated by
- 0.2 x tumour size in cm
  - plus
- grade (1-3)
  - plus
- number of nodes
  - 0 = 1
  - 1-3 = 2
  - >3 = 3
general interpretation is in 10 year survival
- <3.4 over 90%
- 3.4 to 5.4 over 75%
- >5.4 under 55%

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