Devirgilio Pt II

Question 1

H and P for breast mass?

Answer 1

New breast mass in a postmenopausal woman is cancer until proven otherwise
Breast cancer is firm with irregular borders

Question 2

Types of nipple discharge that are more concerning for cancer?

Answer 2

Bloody, spontaneous, unilateral, uniductal, associated with breast mass, in women over 40

Question 3

Risk factors for breast cancer?

Answer 3

Family history, genetic defects (BRCA 1 2) obesity, early menarche, late menopause, nulliparity, childbirth after age 30, alcohol, radiation to chest before age 30

Question 4

Most common causes: palpable breast mass? malignant neoplasm? benign neoplasm?

Answer 4

Palpable: fibrocystic disease
Malignant: Invasive ductal carcinoma
Benign: fibroadenoma

Question 5

Rate of breast cancer in US? What receptors are absent in triple-negative?

Answer 5

Rate: 1 in 8 women

Triple negative: Progesteron, estrogen, HER-2

Question 6

What is the work up for new breast masses?

Answer 6

Triple-test:

physical exam, imaging, tissue sample

Question 7

What imaging is appropriate for breast masses?

Answer 7

Less than 30 yo: Ultrasound

Over 30 yo: Ultrasound plus Mammogram

Question 8

Tissue sampling that distinguishes in situ from carcinoma?

Answer 8

Core needle biopsy

FNA cannot distinguish between the two

Question 9

Metastatic work up for clinically early breast cancer?

Answer 9

CXR, liver chemistries, alkaline phosphatase

Question 10

Additional metastatic work up if high suspicion? What makes high suspicion?

Answer 10

Bone scan, CT abdomen, chest and brain

Suspicion based on: lab tests, clinical stage 3 disease or symptoms

Question 11

Management for early stage breast cancer?

Answer 11

1) Lumpectomy, SLNB, and radiation (BCT)
- Higher local recurrence rate
- Equal survival with 2
or
2) Simple mastectomy with SLND
- no radiation if early stage, but needed if more advanced

Question 12

What is SLNB?

Answer 12

Sentinel Lymph Node Biopsy
2-4 nodes
Less lymphedema than ALND
May need ALND if positive for metastasis

Question 13

Management for stage III cancer?

Answer 13

Treatment is individualized:
Inflammatory breast cancer: neoadjuvant chem followed by radical mastectomy, then radiation
For large tumors, BCT is not an option
For clinically positive axillary lymph nodes, SLNB is not an option, use ALND

Question 14

What drugs are used for HER-2 positive? Premenopausal ER positive? Postmenopausal ER positive?

Answer 14

HER-2: Trastuzumab
Premenopausal ER: Tamoxifen
Postmenopausal ER: Anastrozole (aromatase inhibitor)

Question 15

Who does not receive chemotherapy in breast cancer?

Answer 15

Small tumors (1- cm) with favorable hormonal and molecular characteristics and SLNB negative

Question 16

Complications from breast cancer surgery?

Answer 16

Axillary lymph node dissection can lead to significant morbidity: Lymphedema, nerve injury (long thoracic, thoracodorsal, medial, lateral pectoral nerves)

Question 17

4 watch outs in breast cancer?

Answer 17

Men can get breast cancer
Do not confuse inflammatory breast cancer with cellulitis
Do not ignore breast masses in pregnancy or in younger women
Always obtain a tissue diagnosis if there is a palpable breast mass, do not be fooled by a normal mammogram

Question 18

What is one feature on mammography that helps differentiate between benign and malignant conditions?

Answer 18

Size of calcifications:
Macro calcifications are almost always benign
Micro calcifications are more often associated with malignancy

Question 19

S/sx of endocarditis? Associated conditions? Risk factors?

Answer 19

S/sx: Fever, new murmur, positive blood cultures, Laneway lesions (non-tender lesions on palms and soles) Osler nodes (tender lesions on digits)
Associated: Aortic regurgitation (widened pulse pressure)
Risk factors: Rheumatic heart disease, congenital anomalies (mitral valve prolapse), IV drug use

Question 20

Risk factors for aortic dissection?

Answer 20

hypertension, connective tissue disease (Marfan’s, Ehler’s Danlos, etc), advanced age, atherosclerosis, pregnancy, cocaine use, aortic injury (trauma/catheter), bicuspid aortic valve, aortic coarctation

Question 21

Marfan’s: inheritance pattern, defect, protein, function in aortic dissection?

Answer 21

Inheritance: autosomal dominant
Defect: misfolded proteins
Protein: fibrillin
Function: misfolded fibrillin results in cystic medial necrosis of large vessels, weakening the wall

Question 22

Classification schemes for aortic dissection?

Answer 22

Stanford A & B: A involves the ascending aorta with or without the descending, B involves only the descending after the left subclavian artery.
DeBakey I, II, III: I - entire aorta (ascending and descending) II - only ascending, stopping before the R carotid, III - only descending, starting after the L subclavian

Question 23

Most common type of aortic dissection?

Answer 23

Most common type is Stanford B (descending only), but Marfan’s patients most commonly PRESENT with Stanford A.

Question 24

Life threatening complications of Stanford A dissections?

Answer 24

Interrupted coronary arteries = MI
Interrupted carotid arteries = ischemic stroke
May also dissect into the pericardial sac = acute tamponade

Question 25

Complications of Stanford A or B dissections in descending aorta?

Answer 25

Paraplegia - Intercostal or lumbar artery occlusion = ischemic spinal cord
Mesenteric ischemia - SMA occlusion = abdominal pain out of proportion, nausea, bloody diarrhea
Kidney failure - Renal artery occlusion = Oliguria, high BUN and creatinine

Question 26

Lab tests to order if aortic dissection is suspected?

Answer 26

Blood type and crossmatch

Troponin, CK-MB, EKG: signs of an MI do NOT rule out AD because MI is a possible consequence of AD

Question 27

Imaging in aortic dissection?

Answer 27

CXR may show widened mediastinum
10-15% of cases will not appear on CXR
Positive CXR or high suspicion on H&P = Contrast CT

Question 28

Imaging for hemodynamically unstable patient with suspected AD?

Answer 28

No imaging: OR immediately!!
Transesophageal echocardiography can be performed with patient under general anesthesia in the OR and surgery can immediately follow

Question 29

Principle of management for AD and what drug class should be used? Exception to this rule?

Answer 29

Control blood pressure at a low pressure.
Beta-blockers reduce shear forces in aorta by decreasing the change in pressure over change in time.
Start therapy immediately when AD is suspected.
Exception: patients with aortic regurgitation or tamponade should not receive beta blockers

Question 30

Differences between immediate treatment of Stanford A and B dissections?

Answer 30

Anti-hypertensive therapy first for both!!
A - immediate surgical repair
B - admit to ICU, monitor BP, watch for complications like malperfusion syndrome. Complications or continued expansion of aorta = surgery

Question 31

Incidentally discovered adrenal mass: What to look for in the H&P?

Answer 31

Evidence of hormonal hyper secretion
Cortisol: truncal obesity, fat around head and neck (buffalo hump), muscle wasting makes standing from chair difficult. Amenorrhea and hirsutism in women.

Question 32

Incidentally discovered adrenal mass: Most common adrenal mass? Most common functional adrenal mass?

Answer 32

Nonfunctional benign adrenocortical adenoma

Adenoma associated with cortisol hypersecretion

Question 33

Incidentally discovered adrenal mass: Diagnostic tests for hypercortisolism?

Answer 33

24-h urine free cortisol level
Low-dose dexamethasone suppression test
CT scan

Question 34

Incidentally discovered adrenal mass: Diagnostic test for hyperaldosteronism?

Answer 34

Serum aldosterone:plasma renin ratio greater than 30

CT scan

Question 35

Incidentally discovered adrenal mass: Diagnostic test for pheochromocytoma?

Answer 35

Urine or plasma catecholamine or metanephrine levels

CT scan

Question 36

Incidentally discovered adrenal mass: Management of a functional adenoma?

Answer 36

Adrenalectomy

Question 37

Incidentally discovered adrenal mass: Management of a non-functional adenoma?

Answer 37

Under 4 cm: observation
4 - 6 cm: adrenalectomy if low surgical risk
Above 6 cm: adrenalectomy

Question 38

Incidentally discovered adrenal mass: Biopsy and surgical considerations?

Answer 38

Do not biopsy adrenal masses - functional masses are confirmed with hormone tests, pheochromocytomas may release massive amounts of catecholamines, and adrenocortical carcinomas may seed the biopsy tract.

Beware of short posterior adrenal vein entering IVC with right adrenalectomy

Question 39

Ddx of hypercortisolism?

Answer 39

Exogenous sources: immunosuppression for organ transplant
Adrenal: adenoma, carcinoma, bilateral hyperplasia
Pituitary: ACTH hyper secretion
Lung: Non-small cell lung cancer, bronchial carcinoid

Question 40

Incidentally discovered adrenal mass: Clinical presentation of hyperaldosterone?

Answer 40

Hypertension with hypokalemia. HTN refractive to multiple medications, but very responsive to spironolactone. Hypo-K presents with muscle cramping, muscle weakness, rarely with paralysis

Question 41

Clinical presentation of pheochromocytoma?

Answer 41

Sustained or episodic HTN, and one or more of headache, flushing, palpitations

Question 42

Best imaging modality to evaluate and adrenal nodule? Other option?

Answer 42

Best: Contrast enhanced CT with fine cuts.
Other: MRI

Question 43

What is the surveillance protocol for a non-resected adrenal mass?

Answer 43

Imaging at 6, 12, and 24 months, plus biochemical evaluation of hormones annually for 4 years

Question 44

What is subconical Cushing’s syndrome? Management?

Answer 44

Autonomous (ACTH independent) glucocorticoid (cortisol) production from adrenal gland without obvious signs of hypercortisolism. More common than Cushings. Patients have metabolic conditions (obesity, diabetes, hypertension), and may be cured with resection of the adrenal gland. Resection is recommended in younger patients and in those with evidence of hypercorisolism or significant comorbid conditions related to cortisol.