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FRACS study > Breast, endocrine, head and neck > Flashcards

Breast, endocrine, head and neck Flashcards

1
Q

Reasons for parathyroidectomy in asymptomatic hyperparathyroidism

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

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2
Q

5 Things to look for on a mammogram

A

Mass

Calcifications

Architectural distortion

Spiculation

Skin changes

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3
Q

Benign breast disease can be best grouped into which three categories

  • Give an example of each
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
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4
Q

Benign proliferative breast lesions with atypia

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
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5
Q

Hypertrophy

A

Enlargement of individual cells

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6
Q

Hyperplasia

A

Increase in number of cells

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7
Q

MEN1

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
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8
Q

MEN2

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
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9
Q

What percentage of breast cancers are hormone receptor positive

A

75%

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10
Q

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

A

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

  • this effect continues for years 5-9
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11
Q

What is the role for Ovarian suppression in breast cancer

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
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12
Q

What are the 2 main side effects of Tamoxifen

A

VTE

Uterine carcinoma

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13
Q

Monitoring bone loss in aromatase inhibitor use

How is this treated

A

Dexa scan every 2 years

Treatment with bisphosphonates

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14
Q

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

What should be offered to premenopausal women who may require chemotherapy

A

50%

Fertility consultation and egg banking

Goserelin may reduce this risk significantly

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15
Q

What improvement in recurrence of breast cancer does chemotherapy generally offer

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
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16
Q

What do the AJCC grading guidelines classify as chest wall invasion

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

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17
Q

Usual lymphatic drainage of the breast.

What sites are considered regional vs metastatic disease in breast cancer

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

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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:

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.
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19
Q

Where are the internal mammary nodes

A

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

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20
Q

How are supraclavicular lymph nodes defined anatomically.

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).

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21
Q

To which organs does breast cancer metastasize

A

The four most common sites of involvement are

  • bone
  • lung
  • brain
  • liver

breast cancers also are capable of metastasizing to many other sites

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22
Q

Breast cancer staging:

T1

A
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23
Q

Breast cancer staging:

T2 and T3 disease

A

T2

  • 2-5cm

T3

  • >5cm (not invading chest wall or skin)
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24
Q

Breast cancer staging:

T4a and T4b disease

A
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25
Q

Breast cancer staging:

T4b and T4c disease

A
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26
Q

Breast cancer staging:

Inflamatory breast cancer, T staging chacteristics

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.

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27
Q

Breast cancer staging:

Clinical node staging

A
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28
Q

Breast cancer staging:

Nodal staging:

Macrometastasis vs Micrometastasis vs Isolated tumour cell deposits

A

Macrometastasis

  • >2mm

MIcrometastasis

  • 0.2-2mm

Isolated tumour cell deposits

  • <0.2mm
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29
Q

Breast cancer staging:

Nodal status

Axillary only disease

A
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30
Q

Breast cancer staging:

alphabetical suffixes used for extra axillary nodal disease

A

Internal Mammary

  • Receives suffix b modifier with or without axillary disease

Supraclavicular

  • Receives suffix c modifier with or without axillary disease
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31
Q

Nonmetastatic breast cancer is broadly considered into which two categories

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.
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32
Q

Luminal A type breast cancers

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

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33
Q

Luminal B type breast cancers

A

tend to be:

  • poorly differentiated
  • Low receptor positivity

less likely to respond to endocrine therapy

more likely to respond to traditional chemotherapy

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34
Q

Overview of subtypes of breast cancer

A
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35
Q

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

A

T stage

N stage

M stage

Grade

HER2status

ER status

PR status

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36
Q

Who should receive adjuvant chemotherapy in breast cancer“

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)
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37
Q

Who should get Herceptin

A

HER2 + cancers >1cm

Smaller tumours remain controversial

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38
Q

Special considerations in the treatment of breast cancer

A

Fertility preservation

  • Consider and offer in all premenopausal women

Reconstruction/symmetrization

Multidisciplinary meeting

BRCA status and prophylactic surgery

Psychosocial support

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39
Q

Histology of invasive lobular breast cancer

A

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

E- Cadherin positive

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40
Q

Histology of invasive ductal carcinoma

A

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

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41
Q

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

A
  • Locally advanced
    • T3 or greater
    • N2 or N3
  • Inflammatory breast cancer
  • Signs or symptoms suspicious for metastatic disease
  • Recurrent disease
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42
Q

Phyllodes tumors

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
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43
Q

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

A

Phyllodes tumour

Excision biopsy should be performed

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44
Q

What features are used to identify benign vs malignant phyllodes tumours

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
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45
Q

How is grade assessed in breast cancer

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
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46
Q

Cernea classification

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
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47
Q

What are the epithelial derived thyroid cancers

A

Differentiated

  • Papillary (85%)
  • Follicular (12%)

Undifferentiated

  • Anaplastic (<3%)
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48
Q

Staging investigations in differentiated thyroid cancer

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

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49
Q

Signs and symptoms of locally advanced thyroid disease

A

Dysphagia

Respiratory compromise

Haemoptysis

Rapid tumour growth

Voice changes

Vocal cord paralysis

Tumour fixed to surrounding structures

Exthyroidal extension on USS

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50
Q

Specific risk of thyroidectomy

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
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51
Q

Choice of surgery in differentiated thyroid cancer

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
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52
Q

What is the appropriate starting dose for thyroxine post total thyroidectomy

A

1.6-2mcg/kg/day

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53
Q

Hypocalcaemia

Causes and effects

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
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54
Q

Hypocalcaemia management

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)
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55
Q

How is the extent of neck dissection classified

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
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56
Q

Neck node zones

A
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57
Q

Tissue spaces of the neck:

Prevertebral space

A
  • behind prevertebral fascia
  • descends as far as T3
  • Important in cervical discitis and abscess
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58
Q

Tissue spaces of the neck:

Retropharyngeal space

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
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59
Q

Tissue spaces of the neck:

Parapharyngeal space

A

lateral continuation of retropharyngeal space

bonded laterally to pterygoids and parotid sheath

continuous anteriorly with submandibular space

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60
Q

Tissue spaces of the neck:

submandibular space

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
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61
Q

Ludwigs angina

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.

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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
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
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63
Q

AMAROS trial

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
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64
Q

ACOSOG Z0011 trial

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
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65
Q

What are the goals of radioiodine abation after thyroidectomy for thyroid cancer

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.
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66
Q

What drug can be used to cease lactation

A

Cabergoline

Dopamine agonist

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67
Q

ATA risk stratification in thyroid cancer:

Low risk disease

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
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68
Q

ATA risk stratification in thyroid cancer:

Intermediate risk disease

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)
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69
Q

ATA risk stratification in thyroid cancer:

High risk disease

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)
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70
Q

Aggressive histological variants of papillary cancer

A
  • Columnar
  • Tall
  • Insular
  • Hobnail
  • Hürthle
  • Follicular thyroid cancer
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71
Q

Who should receive Radioiodine ablation after thyroidectomy for thyroid cancer

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
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72
Q

Embryology of the thyroid

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
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73
Q

Lingual thyroid

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
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74
Q

BRCA genes

Inheritance pattern

What cancers are associated

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
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75
Q

BRCA 1:

Life time cancer risk:

Breast

Ovarian

A

Breast

  • 70%

Ovarian

  • 40%
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76
Q

BRCA 2:

Lifetime cancer risk:

Breast

Ovarian

A

Breast

  • 70%

Ovarian

  • 15%
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77
Q

High penetrance genes associated with breast cancer

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

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78
Q

BRCAPlus testing

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
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79
Q

Bethesda Classification

A
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80
Q

What is gynaecomastia

What term is used for non glandular breast enlargement in men

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
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81
Q

Gynaecomastia epidemiology and overview of pathophysiology

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
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82
Q

Physiological gynaecomastia:

Causes

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.
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83
Q

Gynaecomastia lateralisation

A

Gynaecomastia is usually bilateral

  • 10% of cases can involve just one breast
    • always consider the possibility of breast cancer in a unilateral presentation.
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84
Q

Medications that cause gynaecomastia

A

Antiandrogens

  • finasteride
  • bicalutamide

Antihypertensives

  • spironolactone

Antiretrovirals

Hormones

  • oestrogen
  • prednisone

H2 receptors blockers

Antipsychotics

many others

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85
Q

What is the role for surgery in gynaecomastia

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
86
Q

Adolescent gynaecomastia, natural history

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.

87
Q

What are the management options for idiopathic gynaecomastia

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

88
Q

Blood tests in gynaecomastia

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.
89
Q

What hormonal tests are warranted in an adrenal adenoma clinically secreting sex hormones

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
90
Q

Simple breast cysts

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

91
Q

complex breast cysts

A

BIRADS 4-5

  • Thick or complex septation
  • Presence of a solid component
  • Absence of posterior wall enhancement
92
Q

Complicated breast cysts

A

BIRADS 2-3

Homogenous low-level internal echoes due to echogenic debris

  • without:
    • solid components
    • thick walls
    • thick septa
    • vascular flow
93
Q

What is the BIRADS

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

94
Q

BIRADS 0

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Incomplete

Management

  • Recall and or review prior imaging

Malignancy rate

  • N/A
95
Q

BIRADS 1

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Negative

Management

  • Routine screening/surveillance

Malignancy rate

  • Essentially 0%
96
Q

BIRADS 2

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Benign

Management

  • Routine screening/surveillance

Malignancy rate

  • Essentially 0%
97
Q

BIRADS 3

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Prrobably benign

Management

  • Short interval surveillance (6 months)

Malignancy rate

  • >0 but <2%
98
Q

BIRADS 4

  • Assessment
    • subclasses
  • Management
  • Likelihood of malignancy
    • by subclass
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%
99
Q

BIRADS 5

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Highly suggestive of malignancy

Management

  • Tissue diagnosis

Malignancy rate

  • >95%
100
Q

BIRADS 6

Assessment

Management

Likelihood of malignancy

A

Assessment

  • Known biopsy proven malignancy

Management

  • NA

Malignancy rate

  • NA
101
Q

Breast lesions:

Papillary apocrine change

A

Benign non proliferative breast lesion.

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

102
Q

Breast lesions:

Mild hyperplasia of the usual type

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.

103
Q

Breast lesions

Usual ductal hyperplasia

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.

104
Q

Breast lesions:

Intraductal papillomas

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.
105
Q

Breast lesions:

Sclerosing adenosis

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

106
Q

Breast lesions:

Radial scars.

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.

107
Q

Breast lesions:

Fibroadenomas:

Epidemiology and aetiology

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.
108
Q

Breast lesions:

Fibroadenoma:

Histological features and risk of malignancy

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
109
Q

Breast lesions

Atypical Hyperplasia

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%
110
Q

Breast Atypical Hyperplasia:

risk reduction strategies

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

111
Q

What model can be used to predict the lifetime risk of developing a breast cancer.

what is the recommended cut off for risk reducing strategies for breast cancer

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

112
Q

Breast lesions:

Flat epithelial atypia (FEA)

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

113
Q

Breast lesions:

lipoma

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

114
Q

Breast lesions:

Fat necrosis

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

115
Q

Breast lesions:

Giant fibroadenoma

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

116
Q

Breast lesions:

Juvenile fibroadenoma

A

Typical fibroadenomas

most common in the upper outer quadrant

ages 10-18

may grow or regress with time

Excision over 5cm is reasonable

117
Q

Breast lesions:

diabetic mastopathy

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.
118
Q

How might radiological breast density be reported

Why is an assessment of breast density important?

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

  1. breast density affects imaging reliability
  2. dense breasts are an independant risk factor for breast cancer
119
Q

Breast lesions:

Hamartomas

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

120
Q

Breast lesions:

Adenoma

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

121
Q

Breast lesions:

Periductal mastitis

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
122
Q

Breast lesions:

PASH

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.

123
Q

Breast lesions:

Adenomyoepithelioma

A

Rare

benign well circumscribed breast lesion

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

124
Q

What ultrasonograpic features are associated with an increased risk of thyroid malignancy

A
125
Q

What ultrasound features are associated with benign thyroid lesions

A
126
Q

What radiological scoring system can be used to risk stratify thyroid lesions

What parameters are used for scoring

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
127
Q

TIRADS score:

Points interpretation

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
128
Q

TIRADS:

Management based on category

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
129
Q

What system is used for reporting of thyroid cytopathology

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

130
Q

Bethesda System: Diagnostic Category 1

Assessment

Risk of maligancy

Recommended management

A

Category

  • Non diagnostic

Risk

  • 1-4%

Management

  • Repeat FNA with USS guidance
131
Q

Bethesda System: Diagnostic Category 2

Assessment

Risk of maligancy

Recommended management

A

Category

  • Benign

Risk

  • 0-3%

Management

  • Clinical follow up
132
Q

Bethesda System: Diagnostic Category 3

Assessment

Risk of maligancy

Recommended management

A

Category

  • Atypia of undetermined significance or
  • Follicular lesion of undetermined significance

Risk

  • 5-15%

Management

  • Repeat FNA
133
Q

Bethesda System: Diagnostic Category 4

Assessment

Risk of maligancy

Recommended management

A

Category

  • Follicular Neoplasm or
  • Suspicious for a follicular neoplasm

Risk

  • 15-30%

Management

  • Diagnostic surgical lobectomy
134
Q

Bethesda System: Diagnostic Category 5

Assessment

Risk of maligancy

Recommended management

A

Category

  • Suspicious for malignancy

Risk

  • 60-75%

Management

  • Near total thyroidectomy or surgical lobectomy
135
Q

Bethesda System: Diagnostic Category 6

Assessment

Risk of maligancy

Recommended management

A

Category

  • Malignant

Risk

  • 97-99%

Management

  • Near total thyroidectomy
136
Q

Eutopic parathyroid position

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

137
Q

Ectopic parathyroid positions

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.
138
Q

What rare malignancy is associated with long term breast implants

A

BIA ALCL

Breast implant associated anaplastic large cell lymphoma

139
Q

BIA-ALCL

Epidemiology

Cell derivative

Presentation

Prognosis

Aetiology

Management

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
140
Q

SCC head and neck

Risks

A

alcohol

male

smoking

HPV

141
Q

SCC head and neck

staging overview

management

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
142
Q

Rule of thumb of salivary gland tumours

A

the smaller the gland the more likely to be malignant

143
Q

what is the most common benign salivary gland tumour

name 3 others

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
144
Q

What is the most common malignant salivary gland tumour

Name three others

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
145
Q

What are the specific post operative risks of superficial parotidectomy

A

The F’s

  • Formication
  • Fistula
  • Freys syndrome
  • Facial nerve injury
  • Flap necrosis
  • First bite syndrome
146
Q

What is the most common site of origin of unknown primary SCC in head and neck

A

Tonsils

147
Q

Melanoma of the head and neck.

selective neck dissection and superficial parotidectomy

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
148
Q

Painless mass on the roof of the mouth

A

Torus palatinus.

Painless, benign boney protuberance

no surgery required

149
Q

most common site for oral cavity cancer

A

lower lip

due to sun exposure

150
Q

How much lip can be excised without reconstruction required

A

Half

151
Q

Suppurative parotiditis

Who

What

How

A

Elderly, dehydrated

staph aureus

rehydration

antibiotics

152
Q

Bleeding from a long standing tracheostomy

A

Tracheoarterial fistula!

  • Put a finger in or overinflate the cuff to compress against the sternum
  • Take to theatre
    • resection of the innominate artery
153
Q

What is the most common site of a missed parathyroid gland

What is the most common site of an ectopic parathyroid gland

A

It’s normal position

thymus is the most common site of an ectopic gland

154
Q

Zenker’s diverticulum

A

Posterior midline oesophageal false diverticulum

Occurs through Killians triangle

  • bordered by:
    • inferior fibres of inferior constrictor (oblique)
    • upper fibres of crichopharyngeus
155
Q

What is a late complication of radiotherapy for breast cancer

A

angiosarcoma

156
Q

What is the prognosis and treatment for radiation induced angiosarcoma

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

157
Q

What is the usual lag period between radiotherapy and development of angiosarcoma

A

5-8 years

158
Q

What is the benefit of radiotherapy in breast WLE

A

Improved local control

Small survival advantage

159
Q

When is radiotherapy indicated after mastectomy

A

Locally

  • involved margins

To the axilla

  • any nodes
  • T3 tumour
  • high risk disease which comes close to meeting the threshold for radiotherapy
160
Q

What tools can be used to assist in predicting recurrence in DCIS

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
161
Q

breast radiotherapy dose and fractionation

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
162
Q

what effect does radiotherapy have on the risk of lymphoedema

A

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

163
Q

What is a high tangent in radiotherapy

A

Field includes level II nodes

164
Q

Timing to radiotherapy post breast surgery

A

within 3 months

ideally 8-12 weeks post operatively

165
Q

Branchial cleft cysts

A
166
Q

What is Graves disease

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)

167
Q

How is TSH suppression undertaken

why

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

168
Q

Define levels of oncoplastic reconstruction in breast surgery

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
169
Q

What is the radiation exposure of a mammogram

A

0.4mSv

or ~7 weeks of background radiation

170
Q

Treatment of phyllodes tumours

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
171
Q

Prognosis from phyllodes tumours

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

172
Q

Carotid body tumours

AKA

A

Chemodectomas

Paragangliomas

173
Q

what are paragangliomas

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

174
Q

What is the appropriate management of a carotid body paraganglioma

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

175
Q

What are the key operative considerations in carotid body tumours

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
176
Q

Describe how you identify and expose the axillary vein during axillary dissection for breast cancer

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
177
Q

Describe the operative technique to identify and preserve the thoracodorsal nerve in axillary dissection.

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
178
Q

Number needed to screen in breast screening

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
179
Q

Breast screen Aotearoa

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.

180
Q

What is the appropriate resection margin in DCIS

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

181
Q

What benign process may mimic the microcalcification of DCIS

A

Plasma cell mastitis

  • classically involves more than one breast segment
182
Q

What blood tests should be done in someone presenting with a neoplasm associated with MEN1

A

Prolactin

  • Pituitary adenoma

PTH

  • Parathyroid adenoma

Gastrin

  • Gastinoma

Insulin, C peptide and glucose levels

  • insulinoma
183
Q

Aldosterone

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

184
Q

NF1 clinical manifestations

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

185
Q

clinical features of cushings syndrome

A

moon face

plethora

striae

central obesity

buffalo hump

hirsutism

loss of libido

menstrual irregularity

depression or psychosis

proximal myopathy

easy bruising

186
Q

Clinical features of hypercalcaemia

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
187
Q

Clinical features of hyperthyroidism

A

Tachycardia and AF

Sweating

Facial and palmar flushing

Weight loss

Hair loss

Hyperreflexia

Eye signs

  • diplopia
  • exopthalmos
  • lid lag
  • lid retraction
188
Q

Clinical features of hypothyroidism

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
189
Q

Goitre grading

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
190
Q

Subtypes of DCIS

A

Comedo

Cribriform

Micropapillary

Papillary

Solid

191
Q

What is the appropriate excision margin in DCIS

A

2mm

  • wider margins do not convey an additional benefit
  • narrower margins are associated with a 2x increase in recurrence rates
192
Q

At excision for DCIS what is the rate of undiagnosed malignancy in the specimen

A

Overall 10-20%

  • in patients presenting with symptomatic DCIS this is closer to 50%
193
Q

What are the indications for SLNB in DCIS

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
194
Q

How is DCIS graded

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
195
Q

How might the facial nerve be found during parotid surgery

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

196
Q

Who should receive BRCA testing

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
197
Q

benign thyroid nodules

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
198
Q

T staging of thyroid cancer

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
199
Q

Management of Bethesda VI thyroid lesions <1cm in size

A

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

  • Patient
    • radiation
    • family history
  • Tumour
    • invasion
    • nodes
    • mets
200
Q

Management of Bethesda VI thyroid lesions 1-4cm

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
201
Q

Management of Bethesda category VI thyroid lesions >4cm

  • What are high risk features to encourage total thyroidectomy in cancers
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
202
Q

Papillary thyroid cancer:

Who should receive selective lateral nodal dissection.

what is the extent of the recommended dissection

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
203
Q

What is the role for central neck dissection in papillary thyroid cancer

A

Prophylactic considered in

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

Therapeutic

  • for clinically, radiologically or intraoperatively identified abnormal nodes
204
Q

what is the management of medullary thyroid cancer

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
205
Q

What is the management of anaplastic thyroid cancer

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

206
Q

Management of hyperthyroidism in pregnancy

A

Use antithyroid medication

  • PTU in the first trimester
  • Carbimazole from the second trimester onward

RAI is contraindicated

Surgery is rarely necessary

207
Q

Frequency of specific complications of thyroid surgery

A

RLN injury

  • 5% transient
  • 1% permanent

Hypoparathyroidism

  • 10-20% transient
  • 1-2% permanent

Post operative bleeding

  • <1%
208
Q

what are the components of the complete biochemical evaluation for hypercalcaemia

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
209
Q

What testing is necessary to identify FHH in hypercalcaemia

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
210
Q

What genetic profiling has been used in indeterminate FNA of thyroid nodules

what are the limitations of this testing currently

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
211
Q

What simple tool may be used to assess prognosis in breast cancer

what are the parameters

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%

FRACS study (13 decks)

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