Devirgilio Pt II Flashcards
H and P for breast mass?
New breast mass in a postmenopausal woman is cancer until proven otherwise
Breast cancer is firm with irregular borders
Types of nipple discharge that are more concerning for cancer?
Bloody, spontaneous, unilateral, uniductal, associated with breast mass, in women over 40
Risk factors for breast cancer?
Family history, genetic defects (BRCA 1 2) obesity, early menarche, late menopause, nulliparity, childbirth after age 30, alcohol, radiation to chest before age 30
Most common causes: palpable breast mass? malignant neoplasm? benign neoplasm?
Palpable: fibrocystic disease
Malignant: Invasive ductal carcinoma
Benign: fibroadenoma
Rate of breast cancer in US? What receptors are absent in triple-negative?
Rate: 1 in 8 women
Triple negative: Progesteron, estrogen, HER-2
What is the work up for new breast masses?
Triple-test:
physical exam, imaging, tissue sample
What imaging is appropriate for breast masses?
Less than 30 yo: Ultrasound
Over 30 yo: Ultrasound plus Mammogram
Tissue sampling that distinguishes in situ from carcinoma?
Core needle biopsy
FNA cannot distinguish between the two
Metastatic work up for clinically early breast cancer?
CXR, liver chemistries, alkaline phosphatase
Additional metastatic work up if high suspicion? What makes high suspicion?
Bone scan, CT abdomen, chest and brain
Suspicion based on: lab tests, clinical stage 3 disease or symptoms
Management for early stage breast cancer?
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
What is SLNB?
Sentinel Lymph Node Biopsy
2-4 nodes
Less lymphedema than ALND
May need ALND if positive for metastasis
Management for stage III cancer?
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
What drugs are used for HER-2 positive? Premenopausal ER positive? Postmenopausal ER positive?
HER-2: Trastuzumab
Premenopausal ER: Tamoxifen
Postmenopausal ER: Anastrozole (aromatase inhibitor)
Who does not receive chemotherapy in breast cancer?
Small tumors (1- cm) with favorable hormonal and molecular characteristics and SLNB negative
Complications from breast cancer surgery?
Axillary lymph node dissection can lead to significant morbidity: Lymphedema, nerve injury (long thoracic, thoracodorsal, medial, lateral pectoral nerves)
4 watch outs in breast cancer?
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
What is one feature on mammography that helps differentiate between benign and malignant conditions?
Size of calcifications:
Macro calcifications are almost always benign
Micro calcifications are more often associated with malignancy
S/sx of endocarditis? Associated conditions? Risk factors?
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
Risk factors for aortic dissection?
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
Marfan’s: inheritance pattern, defect, protein, function in aortic dissection?
Inheritance: autosomal dominant
Defect: misfolded proteins
Protein: fibrillin
Function: misfolded fibrillin results in cystic medial necrosis of large vessels, weakening the wall
Classification schemes for aortic dissection?
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
Most common type of aortic dissection?
Most common type is Stanford B (descending only), but Marfan’s patients most commonly PRESENT with Stanford A.
Life threatening complications of Stanford A dissections?
Interrupted coronary arteries = MI
Interrupted carotid arteries = ischemic stroke
May also dissect into the pericardial sac = acute tamponade
Complications of Stanford A or B dissections in descending aorta?
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
Lab tests to order if aortic dissection is suspected?
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
Imaging in aortic dissection?
CXR may show widened mediastinum
10-15% of cases will not appear on CXR
Positive CXR or high suspicion on H&P = Contrast CT
Imaging for hemodynamically unstable patient with suspected AD?
No imaging: OR immediately!!
Transesophageal echocardiography can be performed with patient under general anesthesia in the OR and surgery can immediately follow
Principle of management for AD and what drug class should be used? Exception to this rule?
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
Differences between immediate treatment of Stanford A and B dissections?
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
Incidentally discovered adrenal mass: What to look for in the H&P?
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.
Incidentally discovered adrenal mass: Most common adrenal mass? Most common functional adrenal mass?
Nonfunctional benign adrenocortical adenoma
Adenoma associated with cortisol hypersecretion
Incidentally discovered adrenal mass: Diagnostic tests for hypercortisolism?
24-h urine free cortisol level
Low-dose dexamethasone suppression test
CT scan
Incidentally discovered adrenal mass: Diagnostic test for hyperaldosteronism?
Serum aldosterone:plasma renin ratio greater than 30
CT scan
Incidentally discovered adrenal mass: Diagnostic test for pheochromocytoma?
Urine or plasma catecholamine or metanephrine levels
CT scan
Incidentally discovered adrenal mass: Management of a functional adenoma?
Adrenalectomy
Incidentally discovered adrenal mass: Management of a non-functional adenoma?
Under 4 cm: observation
4 - 6 cm: adrenalectomy if low surgical risk
Above 6 cm: adrenalectomy
Incidentally discovered adrenal mass: Biopsy and surgical considerations?
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
Ddx of hypercortisolism?
Exogenous sources: immunosuppression for organ transplant
Adrenal: adenoma, carcinoma, bilateral hyperplasia
Pituitary: ACTH hyper secretion
Lung: Non-small cell lung cancer, bronchial carcinoid
Incidentally discovered adrenal mass: Clinical presentation of hyperaldosterone?
Hypertension with hypokalemia. HTN refractive to multiple medications, but very responsive to spironolactone. Hypo-K presents with muscle cramping, muscle weakness, rarely with paralysis
Clinical presentation of pheochromocytoma?
Sustained or episodic HTN, and one or more of headache, flushing, palpitations
Best imaging modality to evaluate and adrenal nodule? Other option?
Best: Contrast enhanced CT with fine cuts.
Other: MRI
What is the surveillance protocol for a non-resected adrenal mass?
Imaging at 6, 12, and 24 months, plus biochemical evaluation of hormones annually for 4 years
What is subconical Cushing’s syndrome? Management?
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.
