head and neck, endocrine and breast Flashcards
1
Q
neck anatomy1) borders of the anterior neck triangle2) borders of posterior neck triangle3) which contains the carotid sheath4) which contains the accessory nerve and brachial plexus5) what does the accessory nerve inervate6) location of false vocal cords in relation to true vocal cords7) composition of the trachea anterior and posterior
A
1) sternocleidomastoid muscle (SCM), sternal notch, inferior border of digastric muscle2) posterior border of the SCM, trapezius muscle and clavicle3) anterior neck triangle4) posterior neck triangle5) SCM, trapezius, platysma6) false cords are superior to true cords7) U-shaped cartilage and posterior portion that is membranous
2
Q
What do they secrete1) parotid glands2) sublingual glands3) submandibular glands
A
1) mostly serous fluid2) mostly mucin3) 50/50 serous/mucin
3
Q
neck anatomy1) what does the vagus nerve run between2) where does the phrenic nerve run3) where does the long thoracic nerve run
A
1)bw Internal jugular vein and carotid artery2) on top of anterior scalene muscle3) posterior to middle scalene muscle
4
Q
Head anatomy1) Trigeminal nervea-branchesb-actions2) Facial nervea-branchesb-actions3) Glossopharyngeal nervea-actionsb-what does injury affect4) hypoglossal nervea-actionsb-findings in hypoglossal nerve injury5) recurrent laryngeal nerve- innervates all of larynx except what muscle? what nerve innervates that muscle
A
1) a-ophthalmic, maxillary, and mandibular branchesb- sensation to most of face. mandibular branch supplys taste to anterior 2/3 of tongue, floor of mouth and gingiva2) a-temporal, zygomatic, buccal, marginal mandibular and cervical branches (to zanzibar by motor car)b-motor function to face3) a-taste to posterior 1/3 of tongue, motor to stylopharyngeusb-swallowing4) a-motor to all of tongue except palatoglossusb-tongue deviates to the same side of the injury5) innervates all of larynx except cricothyroid which is innervated by superior laryngeal nerve
5
Q
Frey’s syndrome1) after what surgery does it occur2) what nerve is injured3) resulting symptoms
A
1) after parotidectomy if injury of (2)auriculotemporal nerve-> cross-innervates with sympathetic fibers to sweat glands of skin-> gustatory sweating (sweating on cheek area when eats or smells or thinks of food)
6
Q
Name the branches of the thyrocervical trunk in the order that they branch off after it leaves the subclavian artery
A
STAT= 1st- suprascapular artery; 2nd-transverse cervical artery, 3rd- ascending cervical artery, 4th-inferior thyroid artery
7
Q
what does the superior thyroid artery come from
A
1st branch of the external carotid artery
8
Q
what artery is the 1) trapezius flap based on2) pectoralis major flap based on
A
1) transverse cervical artery (2nd branch of thyrocervical trunk)2) either the thoracoacromial artery or the internal mammary artery
9
Q
Describe what they are and rx1) Torus palatini2) Torus mandibular
A
1) congenital bony mass on the upper palate of mouth. no rx.2) same as 1 but on lingual surface of mandible. no rx.
10
Q
What do you take in a:1) Modified radical neck dissection2) radical neck dissection3) what is the mortality difference between the two
A
1) takes omohyoid, submandibular gland, sensory nerves C2-C5, cervical branch of facial nerve, and ipsilateral thyroid2) same as above + accessory nerve (CN XII), SCM, and internal jugular resection. (rarely done)3) no mortality difference, but most morbidity occurs from accessory nerve resection so RND rarely done
11
Q
Oral cavity CA- mouth floor, anterior 1/3 tongue, gingiva, hard palate, anterior tonsillar pillars and lips1) MC CA of the oral cavity, pharynx and larynx2) biggest risk factors3) difference between erythroplakia and leukoplakia4) MC site for oral cavity CA5) what location of tumor is the survival rate lowest6) rx
A
1) Squamous cell cancer2) Tobacco and ETOH3) erythroplakia (flat red patch/lesion on mouth) considered more premalignant than leukoplakia (white patch)4) lower lip5) hard palate tumors-hardest to resect6) wide resection (1cm margin)-for tumors >4cm, clinically positive noses or bone invasion do MRND-Do postop XRT for lesions >4cm, positive margins, or nodal/bone involvement
12
Q
Oral Cavity CA1) Lip CAa- which lesions are most aggressiveb- when do you need flaps2) T/F- In tongue CA you can still operate with jaw invasion? If true, name the procedure3) Verrucous ulcera-what is itb-where is it foundc-risk factord-rx
A
1) a-lesions along the commissure are most aggressiveb-need flap if >1/2 of lip is removed2) True. Commando procedure.3) a-well-differentiated SCC, not aggressive, rare metastasisb-cheekc-oral tobaccod-full cheek resection +/- flap. no MRND!
13
Q
Oral Cavity Ca1) rx of maxillary sinus CA2) Tonsillar CAa-risk factorsb-MCC typec- prognosisd-rx
A
1) maxillectomy2) a-ETOH, tobacco, malesb-SCCc- pts asx until large so 80% have LN met at time of d- rx- tonsillectomy best way to bx, then wide local resection with margins after that
14
Q
Pharyngeal CA1) Nasopharyngeal SCCa- risk factors and presentationb- where does it spread toc- rx2) #1 tumor of nasopharynx in kids and rx3) MC benign neoplasm of nose/paranasal sinuses
A
1) a- EBV, Chinese. presents with nose bleed or obstructionb- posterior cervical neck nodesc-XRT primary therapy (with chemo for advanced disease). NO SURGERY2) lymphoma. rx- chemo3) papilloma
15
Q
Pharyngeal CA1)Oropharyngeal SCCa- sxb- where does it spreadc-rx2) Hypopharyngeal SCCa- sxb-where does it spreadc-rx
A
1) a-neck mass, sore throatb-posterior cervical neck nodes2) a-hoarseness; EARLY metastases*c for both: XRT for tumors <4cm and no nodal or bone invasion. Combined surgery MRND, and XRT for more advanced tumors
16
Q
Pharyngeal CA1_ Nasopharyngeal angiofibromaa-prognosisb-population and sxc-rx
A
1) a- benign tumorb- males <20yo with obstruction or epistaxisc-angio and embolization (usually internal maxillary artery), followed by resection
17
Q
Laryngeal CA1) sx2) rx3) MC benign lesion of larynx
A
1) hoarseness, aspiration, dyspnea, dysphagia2) XRT (if vocal cord only) or chemo-XRT (if beyond vocal cord). Surgery is not primary treatment bc try to preserve larynx, but MRND (includes ipsilateral thyroid lobe) needed if nodes clinically positive.3) papilloma
18
Q
Salivary Gland CA- parotid, submandibular, sublingual and minor salivary glands1) Benign of Malignant. a- Mass in large salivary glandb- Mass in small salivary glandc- MC site for malignant tumor2) Malignant tumorsa- presentationb- site of lymphatic drainagec- rx3) Top 2 malignant tumors of the salivary glands and characteristics and which is v sensitive to XRT
A
1) a- benignb) malignantc- Parotid gland (even though it is large)2) a-painful mass, facial nerve paralysis or lymphadenopathyb-intra-parotid and anterior cervical chain nodesc- resection of salivary gland (ie-total parotidectomy), prophylactic MRND and postop XRT if high grade or advanced disease3) mucoepidermoid CA (#1)- wide range of aggressivenessAdenoid cystic CA (#2)- long, indolent course, propensity to invade nerve roots, very sensitive to XRT
19
Q
Salivary Gland TUmors1) benign tumorsa- presentationb-MC benign tumor, malignant potential and rxc-Warthin’s tumor (submandibular duct)- who gets it, % bilateral and rxd-MC salivary gland tumor in children
A
1)a- painless massb- Pleomorphic adenoma (mixed tumor), malignant degeneration in 5%. rx- superficial parotidectomy. if malignant need total parotidectomyc- males, bilateral in 10%. rx- superficial parotidectomyd-hemangiomas
20
Q
1) MC injured nerve with parotid surgery and resulting deficit2) what nerves do you need to find for submandibular resection
A
1) greater auricular nerve-> numbness over lower ear2) find mandibular branch of facial nerve, lingual nerve and hypoglossal nerve* branches of facial nerve course bw superficial and deep parotid. Main trunk of facial nerve at level of digastric muscle
21
Q
Ear- 1) how to rx Pinna lacerations2) what is cauliflower ear and how to rx3) what is cholesteatoma, presenting sx and rx4) Chemodectomas- what are they and rx
A
1) suture through involved cartilage2_ undrained hematomas that organize and calcify. need to be drained to avoid this3) epidermal inclusion cyst of ear, slow drowing but erode. sx- progressive hearing loss and clear drainage from ear. rx- surgica excision4) vascular tumor of middle ear (paraganglionoma). rx- surgery +/- XRT
22
Q
Ear1) acoustic neuromaa- nerve effectedb- sxc- where can it grow intod- rx2) Ear SCCa- where do they metastasizeb-rx3)MC childhood aural malignancy of middle or external ear
A
1) a-CNVIIIb- tinnitus, hearing loss, unsteadinessc- cerebellar/pontine angled-craniotomy and resection. XRT is alternative to surgery2) a- 20% met to parotidb- resection and parotidectomy, MRND for positive LN or large tumor3) Rhabdomyosarcoma
23
Q
Nose1) when to set nasal fx2) rx of septal heamtoma3) rx of epistaxis4) CSF rhinorrheaa-MC cuaseb-what protein is in CSFc-how to find leakd-rx
A
1) after swelling decreases2) drain to avoid infection and necrosis of septum3) 90% are anterior- pack. for persistent posterior bleeding despite packing/balloon, consider internal maxillary artery or ethmoid artery embolization4) a-cribiform plate fractureb- tau proteinc-can use contrast study to help find leakd-can repair facial fx. may help. Try conservative rx 2-3 weeks, try epidural catheter drainage of CSF. may need transethmoidal repair
24
Q
Neck and jaw1) what is a radicular cyst, appearance on x-ray, and how to rx2) Ameloblastoma- what is it, appearance on x-ray and how to rx3) osteogenic sarcoma- prognosis and rx4) rx of maxillary jaw fx5) rx of TMJ dislocation
A
1) inflammatory cyst at the root of teeth (can cause bone erosion). lucent on xray, rx-local excision or curratage2) slow-growing malignancy of odontogenic epithelium (outside portion of teeth), soap-bubble appearance on CXR. rx- wide local excision.3) poor prog. rx- multimodality including surgery4) wire fixation5) closed reduction
25
Neck and Jaw1) nerve damaged when lower lip numbness2) how to repair stensen's duct laceration, what is prbm with ligation?
1) inferior alveolar nerve damage (branch of mandibular nerve)2) repair over catheter stent. ligation can cause painful parotid atrophy and facial assymetry.
26
Neck and Jaw1) Suppurative parotitisa- MC age groupb-causesc- rxd- prognosis
1) a-elderlyb- dehydration, staph is MC organismc-fluids, salivation, abx, drainage if abscess develops or pt not improvingd- can be life threatening
27
Neck and Jaw1) Sialoadenitisa- what is it and causeb- MC glands affectedc- cause of recurrent sialoadenitisd- rx
1) a- acute infam of a salivary gland related to a stone in the duct; most calculi near the orifice2) submandibular or sublingual glands, 80% of the time3) ascending infection from oral cavity4) incise duct and remove stone, gland excision may eventually be necessary
28
head and neck abscesses1) peritonsillar abscessa- age groupb-sxc- rxx2) retropharyngeal abscessa- age groupb-sxc- what other pt population/disease do you see it ind-rx
1) a- older kids >10yob- trismus, odynophagia, usually doesn't obstruct airwayc- needle aspiration 1st, then drainage through tonsilar bed if no relief in 24hr (may need to intubate to drain. Will self-drain with swallowing once opened)2) a- younger kids s diseased-intubate. drain through posterior pharyngeal wall, will self-drain with swallowing once opened
29
head and neck abscesses cont.1) Parapharyngeal abscess- a- when do you see itb- what causes it's morbidityc- rx2) ludwig's anginaa- what is it and what muscle is involvedb-rx
1) a- all age groups, occurs with dental infections, tonsillitis and pharyngitisb- morbidity from vascular invasion and mediastinal spread via prevertebral and retropharyngeal spacesc- drain through lateral neck to avoid damaging internal carotid and internal jugular veins. NEED TO LEAVE A DRAIN2) -acute infection of the floor of the mouth, involves mylohyoid muscle. MC cause is dental infection of the mandibular teethb- airway control (may spread rapidly to deeper structures and cause obstruction), surgical drainage, abx
30
Preauricular tumors1) what are they2) how to diagnose3) rule of 80% for parotid tumors4) MC distant met site for head and neck tumors
1) parotid tumors until proven otherwise2) superficial lobectomy3) 80% of salivary tumors are in the parotid, 80% of parotid tumors are benign, 80% of benign parotid tumors are pleomorphic adenomas4) lung
31
Posterior neck masses1) what is most likely cause2) how to dx
1) if no obvious malignant epithelial tumor, considered to have hodgkin's lymphoma until proved otherwise2) FNA or open biopsy
32
Neck mass workup1) 1st step2) next step if 1st step nondiagnostic3) 3rd step if above two steps nondiagnostic4) if dx reveals adenocarcinoma, what is the likely primary
1) H and P, laryngoscopy and FNA (best test for dx), can consider antibiotics for 2 weeks with re-evaluation if thought to be inflammatory2) panendoscopy with multiple random biopsies and neck and chest CT3) excisional biopsy (need to be prepared for MRND)4) breast, GI or lung primary
33
Epidermoid CA1) what is it2) work up if found in cervical node without known primary (3 steps in order)3) MC location for occult head/neck tumor
1) SCC variant2) 1st- panendoscopy to look for primary with random bx's2nd- CT scan3rd- if still can't find primary, do ipsilateral MRND and tonsillectomy and bilateral XRT3) ipsilateral tonsil
34
Other head/neck conditions1) esophageal forein bodya-MC locationb- dx and rxc-what determines esophageal perforation riskd- dx steps for pt with fever and pain after EGD for foreign body2) laryngeal foreing body rx3) sleep apneaa- associated complicationsb- who has itc- rx4) complication of prolonged intubation and how to rx
1) a- 95% just below the cricopharyngeusb- rigid EGD under anesthesiac-risk increases with length of time in esophagusd- gastrografin followed by barium swallow to r/o perf2) cough, may need emergent cricothyroidotomy as a last resort3) a-MI, arrhythmia, deathb- obese, micrognathia, retrognathia (snoring and excessive daytime somnolencec- CPAP, uvulopalatopharyngoplasty (best surgical solution), or permanent trach4) subglottic stenosis. rx- tracheal resection and reconstruction
35
1) indications for tracheostomy and advantages2) Median rhomboid glossitis- what is it and rx3) cleft lipa- which palate has defect/ structures involvedb- when to repair. what should you repair simultaneouslyc- sx4) cleft palatea- which palate/structuresb- sxc-when to repair
1) pts who will require intubation for >7-14 days. Decreases secretions, provides easier ventilation and decreases pneumonia risk.2) failure of tongue fusion. no rx3) a-primary palate. lips +/- alveolusb- repair at 10 wks, 10lbs, Hgb 10. repair nasal deformities as well.c-poor feeding4) a-secondary palate- hard and soft palatesb- speech and swallowing can be affected if not closed soon enough. maxillofacial growth can be affected if closed too earlyc- repair at 12 months
36
1) MC benign head/neck tumor in adults2) Mastoiditisa- what is it and why is it badb-what is it a complication ofc- signsd- rx3) Epiglottitisa- why is it now rareb- age affectedc- sxd- rx
1) hemangioma2) a-infection of mastoid cells-> can destroy boneb- untreated acute supportive otitis mediac- ear pushed forwardd- abx, may need emergency mastoidectomy3) a- caused by H. influenza type B and now there is the vaccineb- mainly in kids 3-5yoc- stridor, drooling, leaning forward position, high fever, throat pain, thumbprint sign on lateral neck film. Can cause airway obstructiond- rx- early control of airway and abx
37
Endocrinology1) what does hypothalamus release and where does it go2) what does dopamine inhibit the secretion of3) what does the posterior pituitary secrete and where are they produced4) what does the posterior pituitary release
1) TRH, CRH, GnRH, GHRH and dopamine into median eminence-> passes through neurohypophysis (posterior pituitary) on way to adenohypophysis (anterior pituitary)2) prolactin3) Neurohypophysis- ADH (supraoptic nuclei), Oxytocin (paraventricular nuclei in hypothalamus)4) ACTH, TSH, GH, LH, FSH, prolactin
38
Pituitary1) which part does not contain any cell bodies2) which part does not have its own direct blood supply3) what regulates ADH release4) what part of pituitary comprises 80% of the gland
1) posterior pituitary/neuohypophysis2) anterior pituitary/adenohypophysis (passes thorugh neurohypophysis 1st (portal venous system)3) osmolar receptors in hypothalamus4) anterior pituitary
39
Pituitary Masses1) Cause of bi-temboral hemianopia2) Nonfunctional tumorsa- what are they usuallyb- how do they presentc- rx3) C/I to transsphenoidal resection4) chemical rx of pituitary tumors5) MC pituitary adenoma
1) pituitary mass compresses optic nerve (CN II) at the chiasm2) a-macroadenomasb- mass effect, decreased ACTH, TSH, GH, LH, FSHc- transsphenoidal resection3) suprasellar extension, massive lateral extension, dumbbell-shaped tumor4) bromocriptine5) prolactinoma
40
Prolactinoma1) MC size2) prolactin levels at which sx occur3) sx4)rx5) what is rx in pregnancy6) complications of resection of macroadenoma
1) microadenoma2) >1503) galactorrhea, irregular menses, decreased libido, infertility4, 5) bromocriptine (safe in pregnancy) or cabergoline (both are dopamine agonists),If fail medical rx- transphenoidal resection6) hemorrhage, visual loss, CSF leak, don't do if pt wants pregnancy
41
Acromegaly1) hormone involved2) sx3) MC tumor size4) how to dx5) rx
1) Growth hormone2) HTN, DM, gigantism. can be life-threatening 2/2 cardiac sx (valve dysfnc or cardiomyopathy)3) macroadenoma4) elevated IGF-1 (best test), growth hormone >10 in 90%5)octreotide or transsphenoidal resection, XRT and bromocriptine can be used as secondary therapies
42
1) Sheehan's syndroma- 1st signb- other sxc- caused-rx2) Craniopharyngiomaa- what is it and what is it a remnant ofb- sxc- rxd- frequent post-op complication
1) a- post-partum trouble lactatingb- amenorrhea, adrenal insufficiency and hypothyroidismc0 2/2 pituitary ischemia following hemorrhage and hypotensive episode during childbirthd- hormone replacement2) a- benign calcified cyst, remnants of rathke's pouch; grows along pituitary stalk to suprasellar locationb- endocrine abnormalities, visual disturbances, HA, hydrocephalusc- surgery to resect cystd- diabetes insipidus
43
1) bilateral pituitary massesa- what should you checkb- what is it most likely2) Nelsons syndormea- complication of what surgeryb- sxc- caused-rx3) Waterhouse-Friderichsen syndrome- what causes it and resulting deficiency
1) check pituitary hormone axis. if ok probably metastasis2) a- after bilateral adrenalectomyb,c-inc CRH-> pituitary enlargement->amenorrhea and visual problems (bitemporal hemianopia)and hyperpigmentation from beta-MSH (melanocyte-stimulating hormone), a peptide byproduct of ACTHd- rx- steroids3) adrenal gland hemorrhage after meningococcal sepsis infection --> adrenal insufficiency
44
Vascular supply to the adrenal gland1) superior adrenal2) middle adrenal3) Inferior adrenal4) what does to left adrenal vein drain into5) what does the right adrenal vein drain into
1) inferior phrenic artery2) aorta3) renal artery4) left renal vein5) IVC
45
1) 2 parts of the adrenal gland and innervation for each2) where does adrenal lymph drain to
1) adrenal cortex (no innervation), adrenal medulla (innervated by sympathetic splanchnic nerves)2)lymph drainage to subdiaphragmatic and renal LNs
46
1) diagnostic workup for incidental adrenal mass on CT2) rx of asymptomatic adrenal mass3) followup of incidentaloma if not resected4) MC mets to adrenal5) rx of isolated met to adrenal
1) often benign, check for functioning tumor- urine metanephrines/VMA/catecholamines, urinary hydroxycorticosteroids, serum K with plasma renin and aldosterone levels-consider CXR, colonoscopy and mammogram to check for primary tumor (lung, colon, breast)-if pt has a cancer history with asx adrenal mass, need biopsy2) surgery if ominous characteristics (non-homogenous), >4-6cm, functioning or enlarging. use anterior approach for adrenal CA resection.3) repeat imaging q3mo for 1 year. then yearly imaging4) lung CA (#1), breast, melanoma, renal CA5) some can be resected with adrenalectomy
47
adrenal cortex1) what does it develop from2) name the 3 layers and what is produced in each3) adrenal enzymes4) descibe pathway of cortisol release from hypothalamus to adrenal
1) mesoderm2) (GFR=salt, sugar, sex steroids) Glomerulosa-aldosteronefasciculata-glucocorticoidsreticularis- androgens/estrogens3) 21- and 11-beta hydroxylase are in all zones4) hypothalamus releases corticotropin-releasing hormone--> anterior pituitary gland--> ACTH release--> release of cortisol from adrenal gland
48
adrenal cortex1) when is cortisol peak2) actions of cortisol3) actions of aldosterone4) what stimulates aldosterone secretion
1) diurnal (daily) peak at 4-6am2) ionotropic, chronotropic, increases vascular resistance, proteolysis and gluconeogenesis, decreases inflammation3) stimulates renal sodium resorption and secretion of potassium and hydrogen4) angiotensin II and hyperkalemia (ACTH also does to a small extent)
49
What should you think of if the adrenals are producing excess estrogens and androgens
cancer
50
Congenital adrenal hyperplasia1) what pathway is the enzyme defect in2) MC deficit and resulting change in hormones3) other possible deficit-which deficit is salt-saving vs salt-wasting and resulting effect on BP4) treatment
1) cortisol synthesis2) 21-hydroxylase deficiency-> inc 17-OH progesterone-> inc testosterone* salt-wasting (hypoTN)3) 11-hydroxylase deficiency-> inc deoxycortisone (mineralocorticoid)-> salt-saving (HTN)4)cortisol, genitoplasty
51
Conn's syndrome- what is it1) symptoms2) what distinguishes between primary and secondary disease3) Causes of primary disease4) Causes of secondary disease5) diagnosis6) localizing studies7) what are the pre-op considerations for these patients
Hyperaldosteronism1) HTN 2/2 Na retention without edema, hypokalemia, weakness, polydypsia, polyuria2) renin level- low in primary disease, high in secondary disease3) #1=adenoma (85%), hyperplasia (15%), ovarian tumors and CA (rare)4) more common than primary dz, 2/2 CHF, renal artery stenosis, liver failure, diuretics, Batter's syndrome (renin-secreting tumor)5) salt-load suppresion test (best, urine aldosterone stays high-aldosterone:renin ratio > 20 (labs: dec serum and urine K, inc serum Na, metabolic alkalosis-plasma renin activity low6) MRI, NP-59 scintigraphy (shows hyperfnc adrenal tissue) , adrenal venous sampling last resort7) control HTN and K replacement
52
Hyperaldosteronism (Conn's syndrome)1) rx of adenoma2) rx of hyperplasia3) what to give post op for BL adrenalectomy
1) adrenalectomy2) seldom cured (inc morbidity with bilateral resection)-medical rx 1st (spironolactone-inhibits aldosterone, Ca-channel blocker, potassium-BL resection only done if refractory to med rx. must give fludrocortisone postoperatively
53
Addison disease-what is it1) #1 cause2) #1 primary cause of disease3) other causes4) diagnosis
hypocortisolism, adrenal insufficiency1) withdrawal of steroids2) autoimmune disease3) pituitary disease, adrenal infection/hemorrhage/metastasis/resection4)cosyntropin test-ACTH given, measure urine cortisol and remains low-on labs will have low cortisol, high ACTH and low aldosterone
54
Addison disease/adrenal insuff/hypocortisolism1) acute adrenal insuff sx2) rx3) chronic adrenal insuff sx4) rx
1) hypotension, fever, lethargy, abdominal pain, N/V, dec glucose, inc K2) dexamethasone, fluids, and give cosyntropin test (Dexamethasone dose doesn't interfere)3) hyperpigmentation, weakness, weight loss, GI sx, inc K, dec Na4) corticosteroids
55
Cushing's Syndrome- what is it1) MC cuase2) diagnostic flow chart3) how to localize tumors and diff adrenal adenomas from hyperplasia4) top-3 non-iatrogenic causes of cushing's
hypercortisolism1) iatrogenic2) 1st- measure 24-hr urine cortisol (most sensitive) and ACTH--> if ACTH low (and cortisol high)= cortisol-secreting lesion (adrenal adenoma)--> if ACTH high (and cortisol is hihg)= pituitary adenoma or ectopic source of ACTH (small cell lung CA)2nd- if ACTH high, give high-dose dexamethasone suppresion test.--> if urine cortisol suppressed= pituitary adenoma--> if urine cortisol not suppressed--> ectopic producer of ACTH (ie-small cell lung CA)3) NP-59 scintography4) #1 Pituitary adenoma (80%), #2 Ectopic ACTH (ie-small cell lung CA), #3 adrenal adenoma
56
Discuss the differences in hormone/signaling mlq levels, diagnosis and the treatment for the following causes of hypercortisolism (Cushings)1) Pituitary adenoma2) Ectopic ACTH3) Adrenal adenoma4) Adrenal hyperplasia
1) mostly microadenomas, cortisol suppressed with dexameth-supp-test. dx- MRI vs petrosal samplingrx- transphenoidal removal of tumor. if not possible- do XRT2) cortisol not suppressed with dex-supp-test. dx- Chest and abdominal CT. rx- resection of primary if possible, if not medical suppression3) dec ACTH, unregulated steroid production. rx- adrenalectomy4) micro or macro. rx- metyrapone (blocks cortisol synthesis) and aminoglutethimide (inhibits steroid production). B/L adrenalectomy if medical management fails
57
When is b/l adrenalectomy indicated and what do you need to give postop if operating for cushings
pts with ectopic ACTH from tumor that is unresectable or ACTH from pituitary adenoma that can't be found.for cushings- give steroids postop
58
Adrenocortical carcinoma1) MC age and sex2) what % are functioning tumors3) signs/sx4) what % have adv disease at time of dx5) rx6) 5-year survival
1) females, bimoral (<5yo and 5th decade)2) 50% (cortisol, aldosterone, sex steroids)3) children have virilization 90% of the time (precocious puberty in boys, virilization in females); feminization in men, masculinization in women, abdominal pain, weight loss, weakness4) radical adrenalectomy, debulking helps symptoms and prolongs survival*Mitotane (adrenal-lytic) for recurrent, residual or metastatic disease5) 20%
59
Adrenal medulla1) cell type that comprise it2) hormone production and the rate limiting step3) what converts norepinephrine to epinephrine and where is it found4) T/F all pheochromocytomas produce norepinephrine
1) ectoderm neural crest cells2) tyrosine-> dopa-> dopamine-> norepinephrine-> epinephrine*RLS is tyrosine to dopa (Tyrosine hydroxylase)3) PNMT (phenulethanolamine N-methyltransferase)-only found in adrenal medulla (exclusive producer of epi)4) False- only adrenal pheos produce epi
60
Adrenal Medulla1) role of MAO (monoamine oxidase)2) role of VMA (vanillylmandelic acid)3) where are extra-adrenal nests of neural crest tissue sometimes found
1) breaks down catecholamines, converts norepinephrine to normetanephrine, epinephrine to metanephrine2) produced from breakdown of catecholamines, can be used to check for pheo3) retroperitoneum, most notably in organ of zuckerkandl at aortic bifurcation
61
Pheochromocytoma1) cell type2) where do they arise from3) what is the 10% rule4) what syndromes are they associated with5) what side are they MC on6) which types are most malignant
1) chromaffin cells2) sympathetic ganglia or ectopic neural crest cells. rare, grow slowly3) 10% are malignant, bilateral, in children, familial, extra-adrenal4) MEN IIa and IIb, von Recklinghausen's dz, tuberous sclerosis, Sturge-Weber dz5) right6) extra-adrenal are more likely to be malignant
62
Pheochromocytoma1) symptoms2) how to dx and what test is C/I (why?)3) rx and what is the first step in doing surgery4) pre-operative preparation
1) HTN (often episodic), HA, diaphoresis, palpitations2) urine metanephrines and VMA; VMA is most sensitive test-MIBG scan (norepi analogue) can help identify location if having trouble finding tumor with CT/MRI-Clonidine suppression test-- tumor doesn't respond, keeps catecholamines high*NEVER do venography-> can cause hypertensive crisis3) adrenalectomy- ligate adrenal veins first to avoid spilling catecholamines during tumor manipulation- if unresectable can do tumor debulking-Metyrosine- inhibits tyrosine hydroxylase-> dec catecholamine synthesis4) volume replacement and alpha-blocker (phenoxybenzamine) first to avoid hypertensive crisis. then B-blocker if pt has tachycardia or arrhythmia*if give b-blocker fist can get unapposed alpha-> hypertensive crisis, stroke and heart failure-have Nirpride, Neo-synephrine and antiarrhythmic (ie-amiodarone) ready at surgery
63
Pheochromocytoma1) post op conditions2) other sites for the tumor3) MC site of extramedullary tissue and tumors found in extramedullary tissue4) other causes of falsely elevated VMA
1) persistent HTN, hypotension, hypoglycemia, bronchospasm, arrhythmias, intracerebral hemorrhage, CHF, MI2) vertebral bodies, opposite adrenal gland, bladder, aortic bifurcation3) organ of ZUckerkandl (inferior aorta near bifurcation) is MC. extra-med tissue responsible for medullary CA of thyroid and extra adrenal pheo4) coffee, tea, fruits, vanilla, iodine contrast, labetalol, alpha and beta blockers
64
Ganglioneuroma1) origin- cell type, organs2) rx
1) rare, benign, asymptomatic tumor of neural crest origin in adrenal medulla or sympathetic chain2) resection
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Thyroid1) what is the embryologic origin2) Role of Thyrotropin-releasing factor (TRF)3) role of thyroid-stimulating hormone (TSH)4) how is TRF and TSH regulated by feedback5) what does superior thyroid artery branch from6) what about inferior thyroid artery?7) what supplies the parathyroids and how do you avoid injury to parathyroid glands with thyroidectomy
1) from 1st and 2nd pharyngeal arches (not pouches)2) released from hypothalamus--> anterior pituitary-->TSH release3) released from anterior pituitary--> thyroid gland-> T3 and T4 release (involves cAMP)4) negative feedback from T3/T45) 1st branch off external carotid artery6) off thyrocervical trunk. 7) inferior thyroid artery. ligate close to thyroid to avoid injury to parathyroids
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Thyroid1) IMA artery- how often is it there? and where does it come from/go to2) where does inferior thyroid vein drain3) where does superior and middle thyroid veins drain4)a- what does the superior laryngeal nerve innervate?b-where does it runc- result of injury5) same as 4, but for recurrent laryngeal nerve6) how common is a non-recurrent laryngeal nerve, which side is it MC on7) T/F risk of injury is higher for non-recurrent laryngeal nerve during thyroid surgery
1) occurs in 1%, arises from innominate or aorta and goes to the isthmus2) innominate vein3) internal jugular vein4)a- motor to cricothyroidb- runs lateral to thyroid lobes, close to superior thyroid arteryc- loss of projection and easy voice fatigability (opera singers)5) a-motor to all of larynx except cricothyroidb-posterior to thyroid lobes in tracheoesophageal groove, can track with inferior thyroid artery-Left RLN loops around aorta-Right RLN loops around the innominatec- hoarseness, if bilateral-> airway obstruction-> emergent tracheostomy6) 2%, right side more common7) True
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Thyroid1) what is ligament of Berry2) role of thyroglobulin3) T4:T3 ratio, which is more active and where is it produced4) role of peroxidases5) role of deiodinases6) role of thyroxine-binding globulin
1) posterior medial suspensory ligament close to RLN, need careful dissection2) stores T3 and T4 in colloid3) 15:1. T3 is more active (tyrosine + iodine), produced in periphery from T4 conversion by deiodinases4) link iodine and tyrosine 5) separate iodine from tyrosine6) thyroid hormone transport, binds T3 and T4 in circulation
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Thyroid1) what is the most sensitive indicator of gland function2) What are the tubercles of zuckerland. what nerve runs nearby and should you remove with thyroidectomy3) what cells produce calcitonin4) When to start thyroxine treatment? and what is long-term s/e5) treatment for post-thyroidectomy stridor
1) TSH2) most lateral, posterior extension of thyroid tissue. rotate medially to find recurrent laryngeal nerves. leave this portion with subtotal thyroidectomy 2/2 proximity to RLN3) Parafollicular cells4) if TSH levels fall 50%. osteoporosis is s/e5) open neck and remove hematoma emergently to prevent airway compromis. If bl RLN injury need emergent tracheostomy
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Thyroid Storm1) symptoms2) MC after surgery in pts with what undiagnosed dz3) what can precipitate it4) rx5) describe the wolff-chaikoff effect
1) tachycardia, fever, numbness, irritability, vomiting, diarrhea, high-output cardiac failure (MC cause of death)2) Graves' dz3) anxiety, excessive gland palpation, adrenergic stimulants4) Beta-blockers (1st line), PTU, lugol's solution (KI), cooling blankets, oxygen, glucose*emergent thyroidectomy is rarely/never indicated5) v. effective for thyroid storm- pt given high dose iodine (Lugol's soln, potassium iodide) which inhibits TSH action on thyroid and inhibits organic coupling of iodide-> less T3 and T4 release
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Asymptomatic thyroid nodule1) % benign, MC sex2) how to dx3) rx if a-follicular cellsb- thyroid CAc-cyst fluidd-colloid tissuee- nl thyroid tissue but TFTs elevated4) further testing if FNA indeterminate and rx
1) 90%, females2) get FNA (1st test/best- determinant in 80%) and TFTs3) a- lobectomy (10% risk of CA)b- thyroidectomy or lobectomy + appropriate rxc- drain. If recurs or bloody-> lobectomyd- most likely colloid goiter. give thyroxine. if enlarges-> lobectomye- likely solitary toxic nodule. if asx-monitor. if sx- PTU and Iodine 1314) for 20% indeterminant-> get radionuclide studya-hot nodule->monitor if asx, PTU and I 131 if sxb- cold nodule- lobectomy (more likley to be malignant)
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Thyroid Goiter1) most identifiable cause and rx2) cause if diffuse enlargement but no evidence of functional abnormality3) when to operate and what procedure for nontoxic colloid goiter4) where do the vessels originate ina- substernal secondary goiterb-substernal primary goiterc- mediastinal thyroid tissue
1) iodine def. rx- iodine replacement2) nontoxic colloid goiter3) if causing airway compromise or suspicious nodule do subtotal or total thyroidectomy. subtotal has less risk of RLN injury.4) a- superior and inferior thyroid arteriesb- innominate arteryc- substernal goiter extension likely
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Thyroid abnormalities1) pyramidal lobe- where is it and how common2) lingual lobe-a- where is itb-sxc- malignancy riskd-rxe- T/F it is usually the only thyroid tissue in the pt's who have it3) thyroglossal duct cysta- classic PE findingsb- why do we resect itc- what else should you resect with the cyst and name of procedure
1) 10%, extends from isthmus toward thymus2) a- thyroid tissue that persists in foramen cecum at base of tongueb-dysphagia, dyspnea, dysphoniac- 2% malignancy riskd- thyroxine suppression, abolish with iodine 131*resect if worried about CA or doesn't shrink after medical therapye- true- in 70% it is the only thyroid tissue3) a- moves upward with swallowingb-susceptible to infection, may be pre-malignantc-take midportion or all of hyoid bone along with thyroglossal duct cyst (Sistrunk procedure)
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Hyperthyroidism treatment1) What pts are propylthiouracil (PTU) and methimazole good for2) which treatment is safe with pregnancy3) which treatment is good for pts who are poor surgical risks or unresponsive to PTU4) PTU mechanism of action and s/e
1) good for young pts, small goiters and mild T3/T4 elevation2) PTU3) Radioactive Iodine (131 I)4) inhibits peroxidases and prevents iodine-tyrosine coupling.s/e- aplastic anemia, agranulocytosis (rare)5) inhibits peroxidases and prevents iodine-tyrosine couplings/e- cretinism in newborns (crosses pacenta), aplastic anemia, agranulocytosis (rare)
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Thyroidectomy for hyperpthyroidism1) When should you operate?2) best time to operate in pregnancy3)what operation can you do to leave pt euthyroid
1) cold nodules, toxic adenomas or multinodular goiter unresponsive to medical therapy, pregnant pts not controlled with PTU, compressive sx2) 2nd trimester (dec risk of teratogenic events and premature labor)3) subtotal thyroidectomy
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Grave's disease1) is it hyper or hypothyroid?2) MC sex3) sx4) cause/pathophysiology5) diagnostic studies/labs
1) hyper (MC cause 80%)2) women3) exophthalmos, pretibial edema, a-fib, heat intolerance, thirst, inc appetite, weight loss, sweating, palpitations4) IgG Ab to TSH receptor (long-acting thyroid stimulator=LATS or thyroid-stimulating immunoglobuli5) decreased TSH, inc T3/T4. LATS level, inc 123-I uptake on thyroid scan diffusely in thyrotoxic pt with goiter
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Grave's Disease Treatment1) medical options2) when to operate3) pre-op preparation required for pt4) what are operation choices and cons of each
1) thiamides=PTU (50% recurrence), radioactive iodine 131 (5% recurrence). do medical management first2) if medical manage fails or suspicious nodule, children, or pregnant pt not managed with PTU3) PTU until euthyroid, beta-blocker, Lugol's solution for 14days to decrease friability and vascularity to be started once euthyroid4) bilateral subtotal (5% recurr) or total thyroidectomy (need lifetime thyroxine treatment)
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Toxic Multinodular goiter1) hypo or hyperthyroid?2) sex3) sx4) Pathophysiology5) rx
!)hyper2)women, >50yo, usually nontoxic first3) tachycardia, weight loss, insomnia, airway compromise. Sx can be precipitated by contrast dyes4) caused be hyperplasia 2/2 chronic low-grade TSH stimulation5) Surgery is preferred initial treatment, but can consider trail of radioactive iodide 131 esp in frail or elderly if no compressing or suspicious nodule
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Single Toxic thyroid nodule1) hyper or hypothyroidism2) sex and age3) size at which sx occur4) dx5) rx
1) hyper2) women, younger3) >3cm to be sx; function autonomously4) thyroid scan (hot nodule)- 20% eventually cause sx5) thioamides and 131-I (95% effective); lobectomy if medical rx ineffective
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Hashimoto's thydroiditis1) hypo or hyperthyroid?2) sx3) sex4) risk factors5) what can it cause in the acute early stage6) pathophysiology7) pathology8) rx
1) MC cause of hypothyroidism2) enlarged gland, painless, chronic thyroiditis3) women4) h/o childhood XRT5) thyrotoxicosis6) caused by both humeral and cell-mediated autoimmune disease (microsomal and thyroglobulin Ab). Goiter 2/2 lack of organification of trapped iodide inside gland.7) lymphocytic infiltrate8) 1st line- thyroxine. Partial thyroidectomy if continues to grow despite thyroxine treatment, if nodules appear or if compression.
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Bacterial thyroiditis1) hypo or hyper2) pathophysiology3) signs/sx/TFTs4) rx
1) hypo2) usually 2/2 contiguous spread. MC is bacterial URI (staph/strep)3) normal TFTs, fever, dysphagia, tenderness4) abx. may need lobectomy to r/o CA in pts with unilateral swelling and tenderness. May need total thyroidectomy for persistent inflammation
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DeQuervain's thyroiditis1) hyper or hypothyroid?2) sx and labs3) typical precursor4) rx
1) can be hyperthyroid initially then hypothyroid2) elevated ESR, tender thyroid, sore throat, mass, weakness, fatigue, women3) viral URI4) steroids and ASA.-may need lobectomy to r/o CA in pts with unilateral swelling and tenderness-may need total thyroidectomy for persistent inflammation
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Riedel's Fibrous struma of thyroid1) what is it2) typical symptoms3) associated diseases4) rx
1) woody, fibrous component that can involve adjacent strap muscles and carotid sheath, can resemble thyroid CA or lymphoma (need bx)2) hypothyroidism, compression3) sclerosing cholangitis, fibrotic diseases, methysergide Tx, and retroperitoneal fibrosis4) rx- steroids and thyroxine. May need isthmectomy or tracheostomy for airway sx. if resection needed watch for RLNs
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Thyroid Cancer1) T/F: MC endocrine malignancy in US2) follicular cells on FNA- % chance of malignancy and why3) signs that are concerning for malignancy4) what should you think about with sudden thyroid growth?5) Follicular adenomasa- cancer riskb- make up6) MC type of thyroid CA7) which type is associated with MEN IIa or IIb8) what is the most aggressive thyroid CA
1) true2) 5-10% chance. unable to differentiate between follicular cell adenoma, follicular cell hyperplasia and follicular cell CA on FNA.3) solid, solitary, cold, slow growing, hard; male, age >50, previous neck XRT, MEN IIa or IIb4) hemorrhage into previously undetected nodule or malignancy5) a- benign, no increased risk, but must remove to prove just an adenomab- colloid, embryonal, fetal6) papillary thyroid CA7) medullary thyroid CA8) anaplastic thyroid CA
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papillary thyroid carcinomaa- prognosisb- risk factorsc- what predicts worse prognosisd- T/F: prognosis is based on lymph spreade- where does it metastasize to?f-T/F: adults are more likley to be node positive than childreng-pathologyh-rx
a- least aggressive, slow growing, best prognosis, 95% 5-yr survival. death 2/2 local dzb-women and children, childhood XRT (MC tumor following XRT)c-older age >40-50yod- false.. lymphatic spread 1st but is not prognostic. prognosis based on local invasione- lung (rare)f-False. Children are more likely than adultsg-psammoma bodies (Calcium) and Orphan Annie nuclei, many are multicentrich- rx:* if minimal/incidental ( lobectomy.*TOTAL thyroidectomy for b/l lesions, multicentricity, h/o XRT, positive margins of tumors >1cm*Ipsilateral MRND- if clinically positive nodes or extrathyroidal tissue involvement*Radioactive Iodine (I-131)-4-6 wk sp surgery if mets, residual local dz, positive LN or capsular invasion.*XRT only for unresectable dz not responsive to I-131
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Enlarged lateral neck LN that shows normal-appearing thyroid tissue1) what is it2) rx
1) Papillary thyroid CA with lymphatic spread (lateral aberrant thyroid tissue)2) total thyroidectomy and MRND; 131-I 4-6wks post-op
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Follicular thyroid CA1) type of spread and MC site2) what % have mets at diagnosis3) FNA with follicular cells only- % chance of malignancy and rx4) rx5) prognosis
1) Hematogenous spread (bone most common)2) 50% (more aggressive than thyroid papillary cell CA3) 10% chance of malignancy, need lobectomy4) lobectomy- if shows adenoma of follicular cell hyperplasia no other rx*if follicular CA-> total thyroidectomy for lesions >1cm or extrathyroidal dz* need ipsilateral MRND if clinically positive cervical nodes or extrathyroidal tissue involved.*I-131 for lesions>1cm or extrathyroidal disease (4-6wk after surgery5) 50% 5-year survival, prognosis based on stage
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Medullary thyroid cancer1) usually the first manifestation of what syndromes2) cell type and what does it secrete and resulting symptoms3) pathology4) what else do you need to screen for in pts with this CA?5) how does it spread?6) early mets to where?7) rx8) how can you monitor for dz recurrence?9) prognosis
1) MEN IIa or IIb (diarrhea)2) parafollicular C cells- secrete calcitonin- can cause flushing and diarrhea3) amyloid deposition4) hyperparathyroidism and pheochromocytoma5) lymphatic- most have involved nodes at the time of diagnosis6) lung, liver, bone7) rx- total thyroidectomy with central neck node dissection *MRND if clinically positive nodes or if extrathyroidal dz presentfor MEN IIa (at 6yo) and MEN IIb (at 2yo) do prophylactic thyroidectomy and central node dissection*can't cure if liver or bone mets so don't attempt*XRT for nonresectable local and distant mets8) calcitonin levels9) 50% 5-yr survival, based on presence of regional and distant mets (more aggresive than follicular and papillary CA)
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Hurthle cell Carcinoma1) prognosis2) where it mets to3) rx
1) most are benign (Hurthle cell adenoma), presents in older pts2) mets go to bone and lung if malignant3) total thyroidectomy, MRND for clinically positive nodes
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Anaplastic thyroid CA1) pt population seen in2) prognosis3) rx
1) elderly pts with long-standing goiters2) rapidly leathal (0% 5-yr survival), usually beyond surgical management at time of diagnosis3) total thyroidectomy if resectable (rare), can do palliative thyroidectomy for compressive sx or do chemo-XRT
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What thyroid cancers is XRT effective for
papillary, follicular, medullary, and hurthle cell thyroid CA
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Radioactive Iodide treatment (I-131)1) what thyroid CA is it effective for2) can it cure mets?3) when should you give it in relation to surgery?4) when should you thyroid replacement in relation to I-131? and what does it do?5) side effects6) indications for use
1) papillary and follicular ONLY2) bone and lung mets yes3) 4-6 wk after surgery when TSH levels highest4) give thyroid replacement (thyroxine) after I-131 bc it would suppress TSH and uptake of I-131 if given before. It supresses TSH and slows metastatic disease5)sialoadenitis, GI sx, infertility, bone marrow suppression, parathyroid dysfunction, leukemia6) recurrent CA, primary inoperable tumor 2/2 local invasion, tumor >1cm or extrathyroidal dz (if metastatic dz need to do total thyroidectomy first so that I-131 taken up by metastatic lesions
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Parathyroid anatomy1) embryologic origin of a) superior parathyroids and what is it associated withb) locationc) inferior parathyroids and what is it associated withd) location2) blood supply to superior and inferior parathyroid
1) a-4th pharyngeal pouch (associated with thyroid complex)b- lateral to recurrent laryngeal nerves (RLNs), posterior surface of superior portion of gland, above the inferior thyroid arteryc- 3rd pharyngeal pouch, associated with thymusd- medial to RLNs, more anterior, below inferior thyroid artery. However, more variable locations and more likely to be ectopic (ie-tail of thymus MC, anterior mediastinum, intrathyroid, tracheoesophageal groove)2) Inferior thyroid artery
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effect on serum Ca and PO4 of:1) PTH 2) Vitamin D3) Calcitonin4) Normal levels ofa- Ca; b-PTH; c-PO4; d-Cl
1) In Kidney- increases serum Ca reabsorption in distal convoluted tubule, decreases PO4 reabsorptionIn bowel-inc Vit D production in kidney (Inc 1-OH hydroxylation)-> inc Ca-binding in intestine-> inc Ca reabsorptionIn bone- inc osteoclasts to release Ca and PO42) inc intestinal Ca and PO4 absorption by increasing Ca-binding protein3) decreases serum Ca (dec bone Ca resorption= osteoclast inhibition, and inc urinary Ca and PO4 excretion)4) a-8.5-10.5 (iCa 4.4-5.5)b-5-40 pg/mlc- 2.5-5.0d-98-107
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1) MC cause of hyperparathyroidismPrimary hyperparathyroidism2) who gets it3) cause4) diagnostic labs: effect on Ca, PO4, Cl to PO4 ratio, renal cAMP, HCO3-5) associated acid-base derrangement6) symptoms if there
1) previous thyroid surgery2) women, older age3) autonomously high PTH4) inc Ca, dec PO4, Cl-:PO4->33, inc renal cAMP, HCO3- excreted in urine5) hyperchloremic metabolic acidosis6) most have no sx, just incidental inc Ca on routine labs. Sx- muscle weakness, myalgia, nephrolithiasis, pancreatitis, PUD, depression, bone pain, pathologic fractures, AMS, constipation, anorexia. Can get HTN from renal impairment
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What is Osteitis fibrosa cystica and with what dz is it found
Brown Tumors- bone lesions from Ca resorption, characteristic of hyperparathyroidism
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Primary Hyperparathyroidism1) Indications for Surgery2) what % of pts havea-single adenomab- multiple adenomac- diffuse hyperplasiad- parathyroid adenocarcinoma3) treatment for each of #24) special considerations for rx in pregnancy
1) symptomatic dz, asymotomatic dz with Ca>13, dec Cr clearance, kidney stones, substantially dec bone mass or pregnancy2) a- 80%, b- 4%, c-15% (pts with MEN I or IIa have 4-gland hyperplasia) d- v. rare, can get v. high Ca3) a and b- resection + inspect other glands to r/o hyperplasia or multiple adenomasc- resect 3.5 glands or total parathyroidectomy and autoimplant (don't bx all glands)d- radical parathyroidectomy + take ipsilateral thyroid lobe4) do surgery in 2nd trimestor. hyperCa increases risk of still birth if not resected
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Interop considerations for parathyroidectomy1) why do a frozen section2) why check PTH levels3) where to look for missing gland4) what to do if can't find gland5) where is MC location for gland at reop for a missing gland
1) can verify tissue2) should go to less than 1/2 of preop value in 10minutes3) inferiorly in thymus tissue, near carotids, vertebral body, superior to pharynx, thyroid4) close and follow PTH. if still high, get sestamibi scan to localize5) normal anatomic position
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2 causes of hypocalcemia after parathyroidectomy and PTH and HCO3- levels in each
1) Bone hunger- normal PTH, decreased HCO3-2) Aparathyroidism- decreased PTH, normal HCO3-
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MC cause of1) persistent hyperparathyroidism after parathyroidectomy2) recurrent hyperparathyroidism
1) missed adenoma remaining in the neck2) occurs after period of hypocalcemia or normocalcemia-new adenoma formation-tumor impants at original operation that have grown-recurrent parathyroid CA
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1) risks of reoperation after parathyroidectomy2) what is sestamibi scan best for
1) inc risk of RLN injury and permanent hypoparathyroidism2) preferential uptake by overactive parathyroid gland-> good for picking up adenomas but not 4-gland hyperplasia, best for picking up ectopic glands
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Secondary Hyperparathyroidism1) cause2) results/harmful effect seen3) rx
1) renal failure pts-> inc PTH in response to low Ca2) ectopic calcification and osteoporosis3) Ca supplement, Vitamin D, control diet PO4, PO4-binding gel, dec aluminum.-surgery (total parathyroidectomy with autotransplant or subtotal parathyroidectomy) for bone pain (MC indication), fractures or puritis (80% relief)
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Tertiary hyperparathyroidism1) what pts/cause2) lab values3) rx
1) renal disease corrected with transplant but still overproduce PTH2) same as primary hyperparathyroidism/hyperplasia3) subtotal or total parathyroidectomy with autotranspalntation
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Familial Hypercalcemic Hypocalciuria1) labs2) cause/defect3) rx
1) increased serum Ca (9-11), normal PTH (30-60), decreased urine Ca (would be increased if hyperparathyroidism)2) defect in PTH receptor in distal convoluted tubule of the kidney that causes increased Ca resorption3) nothing, Ca not that high
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Pseudohypoparathyroidism- cause
Defect in PTH receptor in kidney-> doesn't respond to PTH
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Parathyroid CA1) labs2) MC site for mets3) rx4) prognosis and cause of death
1) inc Ca (extremely high), PTH, alk phos 2) lung3) wide en block excision (parathyroidectomy and ipsilateral thyroidectomy)4) 50% 5-year survival, mortality due to hypercalcemia-recurrence in 50%
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MEN syndromes1) inheritance2) MEN Ia- three tumors and treatmentb- which is first to cause symtomsc-which is most morbidd- which do you need to treat first if simultaneous3) MEN IIaa-3 tumorsb- which is 1st to cause symtomsc- which is MC to cause deathd- which do you need to treat first if simultaneous4) MEN IIba-3 tumorsb- which is 1st to cause symtomsc- which is MC to cause deathd- which do you need to treat first if simultaneous5) what genes are involved in each syndrome
1) AD, 100% penetrance (derived from APUD cells=amine precursor uptake and decarboxylation)2) Parathyroid hyperplasia (1st to cause sx. rx- 4-gland resection with autotransplantation); pancreatic islet cell tumor- MC is gastrinoma, 50% multiple 50% malignant, most morbid; pituitary adenoma (MC is prolactinoma- correct hyperparathyroidsm 1st if simultaneous tumors)3) parathyroid hyperplasia, medullary CA of thyroid (nearly all pts, 1st to become symptomatic, #1 cause of death, sx-diarrhea, often B/L); pheochromocytoma (often B/L, nearly always benign). Correct pheo first if simultaneous tumors4) medullary thyroid CA (diarrhea, often B/L, nearly all pts, 1st to cause sx, #1 cause of death), Pheo (often B/L/benign, treat first if simultaneous), mucosal neuromas, marfan's habitus, MSK abnormalities5) MEN I- MENIN gene; MEN IIa and IIb-ret proto-oncogene
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Hypercalcemia1) causesa) which type of diuretic can causeb) what is milk-alkali syndromec) what granulomatous diseases caused) malignant causese) other causes2) hypercalcemic crisis- cause and treatment3) how to differentiate bw breast CA mets to bone, small cell lung CA and other hematologic malignancies by lab values
1) a-thiazide diureticsb- excessive intake of milk and Ca supplementsc-TB and sarcoidosisd-hematologic (25%)- lytic bone lesions; nonhematologic (75%)- CA that release PTHrP (small cell lung CA and breast CA)e- hyperparathyroidism, hyperthyroidism, familial hypercalcemic hypocalciuria, immobilization, excess vitamin D2) usually 2/2 surgery in pts with pre-existing hyperparathyroidism. rx- fluids (NS) and lasix (furosemide)3) Breast CA mets and small cell lung CA release PTHrP-> hypercalcemia and increased urinary cAMPhematologic malignancies cause bone destruction with hypercalcemia and low urinary cAMP
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Mithramycin-1) what does it treat2) mechanism of action3) side effects
1) hypercalcemia for malignancies or failure of conventional rx.2) inhibits osteoclasts3) liver, renal and hematologic S/E's
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Breast Anatomy1) what embryologic structure is it formed from?2) what hormone is responsible fora- duct development, b-lobular dev't3) what hormone synergizes with estrogen and progesterone4) what arteries supply the breast
1) ectoderm milk streak2) a- estrogen, b- progesterone3) prolactin4) internal thoracic artery, intercostal arteries, thoracoacromial artery and lateral thoracic artery
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Breast Cyclic changes- hormone responsible for:1) increased breast swelling, growth of glandular tissue2) increased maturation of glandular tissue3) withdrawal causes menses4) cause ovum release5) lack of these after menopause result in atrophy of breast tissue6) what does baston's plexus do?7) where is lymph drainage to?8) what is the N of TMN for disease in supraclavicular nodes?9) MC cause of primary axillary adenopathy10) what do cooper's ligaments do
1) estrogen2) progesterone3) progesterone4) LH/FSH surge5) estrogen and progesterone6) valveless vein plexus allows direct hematogenous metastases of breast CA to spine7) 97% axillary LN, 2% to internal mammary nodes (independent of breast quadrant)8) N39) lymphoma10) suspensory ligament, divides breast into segments. If breast CA affects, can dimple skin
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Breast nerves1) long thoracic nervea- what does it innervateb- what does injury result inc- what does lateral thoracic artery supply2) thoracodorsal nervea- what does it innervateb-result of injuryc- what does thoracodorsal artery supply3) medial pectoral nerve- what does it innervate4) lateral pectoral nerve- what does it innervate5) Intercostobrachial nervea- where does it branch off fromb- what does it innervatec- where to find itd- consequence of transection
1) a- serratus anteriorb-winged scapulac- serratus anterior2) a- latissimus dorsib-weak arm pull-ups and adductionc- latissimus dorsi3) pectoralis major and minor4) pectoralis major5) a- lateral cutaneous branch of 2nd intercostalb- sensation to medial arm and axillac- just below axillary vein when doing ax dissectiond- no major consequence
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Benign breast dz1) abscessa- associated withb- MC causesc-rx2) infectious mastitisa- associated with b-MC causec- possible cause in nonlactating womend- rx3) Periductal mastitis (aka mammary duct ectasia or plasma cell mastitis) a- sxb-risk factorsc- bx findings/ pathd- rx
1) a- breast feedingb- staph #1, strepc- stop breast feeding, breast pump, abx, I&D2)a- breast feedingb-staphc- inflammatory (actinomyces) or autoimmune dz (SLE)d- if nonlactating may need breast bx to r/o necrotic CA (incisional bx including skin). If lactating, continue to lactate, warm compress and analgesic. if not improved in 24hr start abx3) a-noncyclical mastodynia, erythema, nipple retraction, creamy discharge from nipple, can have sterile or infected subaleaolar abscessb- smoking, nipple piercingc- dilated mammary ducts, inspissated secretions, marked periductal inflamationd- if creamy (non-bloody) discharge and no nipple retraction-> abx and reassureif not or recurs, need to r/o inflammatory breast CA via incisional bx
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Benign Breast Dz1) Galactocele- what is it, when does it occur and rx2) Galactorrhea: a) causes, b)common sx in females3) Gynecomastia: a)causes, b) rx, c) how to determine it is there in males4) neonatal breast enlargement: a) cause, b) rx5) accessory breast tissue: a) where is it MC6) where are accessory nipples found7) what is frequently compromised with breast reduction
1) breast cyst filled with milk, occurs with breast feeding. Tx- aspirate or I&D2) a) caused by increased prolactin (piruitary adenoma), OCPs, TCAs, phenothiazines, metoclopramide, alpha-methyl dopa, reserpineb) amenorrhea3) a- cimetidine, spironolactome, marijuana or idiopathic (MC)b- likely will regress, can resect if cosmetic deforming or social problemsc-2-cm pinch4) 2/2 circ maternal estrogen, will regress (no rx)5) axilla6) anywhere from axilla to groin (MC breast abnormality)
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Benign Breast disease1) Components of Poland's syndrome2) Mastodyniaa) dx, b) rx, c) what should patients discontinue,d) MCC of cyclic mastodynia, e) MCC of continuous mastodynia3) Mondors disease-what is it a) causes, b) location, c) rx
1) hypoplasia of chest wall, amastia, hypoplastic shoulder, no pectoralis muscle2) a) hx and PE, b/l mammogramb) danazol, OCPs, NSAIDs, evening primrose oil, bromocriptinec) caffeine, nicoteine, methylxanthinesd) fibrocystic diseasee) acute or subacute infection- more refractory to treatment3) superficial vein thrombophlebitis of breast; feels cordlike, can be painfula) trauma and strenuous exerciseb) usually in lower outer quadrantc) NSAIDs
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Benign Breast disease1) Fibrocystic diseasea- typesb-sxc-which types have CA risk and rx
1) a- papillomatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis, epithelial hyperplasia, ductal hyperplasia and lobular hyperplasiab- breast pain, nipple discharge (yellow-brown), lumpy breast tissue varies with hormonal cyclec-atypical ductal or lobular hyperplasia- resect these lesions (with atypical hyperplasia don't need negative margins, just remove suspicious areas
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Benign Breast dz1) Intraductal papillomaa- sxb- malignant potentialc- how to find and rx
1) a- bloody nipple discharge (MC cause), small, nonpalpable, close to nippleb- NOT premalignantc- get contrast ductogram to find then needle localization. rx- subareolar resection of involved duct and papilloma
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Benign Breast dz1) Fibroadenomaa-sxb-pathc-mammogram findingsd-in pts under 40yo, what do you need to be able to just observee-rx in teenagers and younger childrenf- rx in pts over 40yo
1) a- painless, slow-growing, well circumscribed, firm, rubbery mass (can be >5cm), can change with menstrual cycle and pregnancyb- fibrous tissue compressing epithelial cellsc- large, coarse calcifications (popcorn lesions) on mammo from degenerationd-need all 3 of the following:-clinically benign feeling-US or mammo consistent with fibroadenoma-FNA or core needle bx shows fibroadenoma*If not all 3 true, or continues to enlarge need excisional bx to ensure dxe- avoid resection bc can affect breast developmentf-excisional biopsy
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Nipple discharge1) t/f: MC benign2) dx3) MC cause and rx fora- Green dischargeb- Bloody dischargec- Serous discharged-spontaneous discharge4) management of nonspontaneous discharge
1) true2) history, PE and b/l mammogram3) a- fibrocystic disease. rx- if cyclic and nonspontaneous just reassure ptb- MC intraductal papilloma but occas ductal CA- need ducotogram with excision of mass and ductc- worrisome for CA- especially if only from 1 duct. rx-excisional biopsy of ductal aread- worrisome for CA-> excisional bx of ductal area. May have to do complete subareolar resection if area cannot be properly identified.e- nonspontaneous= occurs with pressure, tight graments, exercise etc. not as worrisome, may need excisional bx if bloody
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Ductal Carcinoma in Situ (DCIS)1) path/description2) malignant potential3) PE and mammogram findings4) must aggressive subtype and rx5) Criteria for increased recurrence risk6) rx
1) malignant cells of ductal epithelium without invasion of basement membrane2) considered premalignant, 50% get ipsilateral CA if not resected; 5% get contralateral CA3) usually not palpable, mammo shows cluster of calcifications4) Comedo pattern- has necrotic areas. rx- simple mastectomy bc high risk for multicentricity, microinvasion and recurrence5) Comedo type or lesions>2.5cm6) lumpectomy and XRT; need 1cm margins (NO ALND or SLNB), possibly tamoxifen** if high grade (comedo type, multicentric, multifocal) or not ammenable to lumpectomy/can't get good margins need to do simple mastectomy
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Lobular carcinoma in situ (LCIS)1) malignant potential2) MC age of pt3) MC type of CA associated with LCIS4) rx and do you need negative margins?
1) not premalignant, but marker for malignancy- 40% get breast CA in either breast2) premenopausal3) ductal CA4) nothing, tamoxifen or bilateral subcutaneous mastectomy. DON'T need ALND or negative margins
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Which of the following is not an indication for surgical biopsy after core biopsy?Atypical ductal hyperplasiaAtypical lobular hyperplasiaRadial scarLobular carcinoma in Situcolumnar cell hyperplasia with atypiafibrous tissue compressing epithelial cells in teenagerpapillary lesionslack of concordance bw mammo and histologic dxnondiagnostic specimen
fibrous tissue compressing epithelial cells in a teenager= benign fibroadenoma
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Breast CA1) what country has lowest rate2) US breast CA risk3) how much does screening reduce mortality?4) what percent have negative mammo and US5) typical clinical features6) symptomatic breast mass wu ina- 40years old
1) japan2) 12% (1 in 8) of all women, 5% in women with no risk factors3) 25%4) 10%5) distortion of normal architecture, skin/nipple distortion or retraction, hard/tethered/indistinct borders6) a-need US and core needle bx. If clinical exam or US indeterminate or suspicious for CA need mammogramb- need B/L mammogram, US and Core needle bx*if Core Needle bx indeterminate, non-diagnostic or non-concordant with PE/imaging studies, need excisional bx for both
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Breast CA1) work up of cyst fluid- when do you need cyst excisional bx2) difference bw FNA and core needle biopsy3) mammography sensitivity and specificity and how big mass needs to be to be detected4) mammographic findings that suggest CA
1) if cyst fluid is bloody, clear and recurs or complex cyst2) Core bx gives architecture, FNA only gives cytology3) 90% sensitivity/specificity, must be >5mm to detect4) irregular borders, spiculated, multiple clustered, small, thin, linear, crushed-like and/or branching calcifications, ductal asymmetry, distortion of architecture
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Management of breast masses based on FNA or CNbx- treatment if:1) malignant2) suspicious3) atypia4) nondiagnostic5) benign
1) definitive therapy2) surgical bx3) surgical bx4) repeat CNbx or surgical bx5) possible observation if concordant, otherwise excisional bx
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BI-RADS classification of mammographic abnormalities: describe the assessment and recommendation for each category 1-5
Category 1) negative- routine screening2) benign- routine screening3) probably benign- short-interval f/u mammo4) suspicious (ie- indeterminate calcifications or architecture)- get CN Bx (definite probability of CA)5) Highly suggestive of CA (suspicious calcifications or architecture)-> get CN bx, high prob of CA
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Management of:1) BI-RADS 4 lesion and CN bx shows:a- malignancyb- nondiagnostic, indeterminate or benign and non-concordantc- benign and concordant2) BI-RADS 5 lesion and CNBx shows:a-malignancyb- any other finding
1)a- follow appropriate rx for diagnosisb- needle localized excisional bxc-6-mo fu mammo2) a- follow appropriate rxb- needle localized excisional bx
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Breast CA screening recs1) when to get mammos2) high risk pt screening
1) every 2-3 years after age 40, then yearly after age 502) mammogram 10years before the youngest age of diagnosis of breast CA in first-degree relative
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Breast Node levels1) describe location of node levels I-III2) location of Rotter's nodes3) what level nodes should you take in an axillary LN dissection4) T/F nodes are most imp prognostic factor5) MC site for distant mets in breast CA6) what tumor locations have increased risk of multicentricity
1) I-lateral to pectoralis minor; II- beneath/posterior to pec minor; III- medial to pec minor2) bw the pec major and pec minor muscles3) levels I and II (take level III if grossly involved)4) true, survival is directly related to the number of positive nodes:0 nodes=75% 5-year survival; 1-3nodes=60%; 4-10nodes=40%5) bone (also goes to lung, liver, brain)6) subareolar and central tumors
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TMN definitions for breast CA1) difference bw T1-42) diff bw N0-33) diff bw stage 0-IV
1) T15cm; T4 has direct extension into chest wall, skin edema or ulceration, satellite skin nodules or inflammatory carcinoma2) N1 has 1-3 internal mammary nodes positiveN2 has 4-9 positive nodesN3 has 10+ positive nodes3) Stage 0 is Tis; stage IIa T0-1 with only 1node or T2 no nodes; stage IIb is T2N1 or T3N0; stage IIIa is any N2 or T3N1; stage IIIc is any N3; IV has distant met
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Breast Cancer Risk- Classify the following as Greatly Increased risk (RR>4), Moderately increased (RR2-4) and lower increased risk (RR35yo
Greatly increased (RR4+)= BRCA gene with fam hx, 2+ relatives with premenopausal or b/l breast CA, DCIS, LCIS, fibrocystic disease with atypical hyperplasiaModerately increased (RR2-4)= prior breast CA, radiation exposure, first degree relative with breast CA, age 1st birth >35yoSlightly increased (RR<2)=nulliparity, proliferative benign disease, early menarche, ETOH use, obesity, late menopause, HRT
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BRCA I and II1) risk of the following CA in BRCA I/ II respectivelya-female breast CAb-ovarian CAc-male breast CA2) besides mastectomy what other surgeries should you consider3) how much is CA risk increased if 1st degree relative has B/L, premenopausal breast CA?
1) a- 60% lifetime risk for bothb-BRCA I- 40%; BRCA II- 10%c-BRCA I-1%; BRCA II- 10%2) TAH and BSO if BRCA + fam h/o breast CA3) risk increased to 50%
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When should you consider prophylactic mastectomy
BRCA gene +family hx; or LCIS+ high anxiety, poor access to followup, difficult lesion or pt preference
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Receptors1) what women are positive ER/PR receptors more common in2) Do PR or ER positive have better prog3) what % is negative for both ER/PR
1) postmenopausal2) PR is better, but together they are the best3) 10% of breast CA is both ER and PR negative
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Male breast CA1) MC type2) prognosis3) risk factors4) rx
1) ductal2) poorer- most have late presentation with increased pectoral muscle involvement3) XRT, steroids, family hx, Klinefelter's syndrome4) modified radical mastectomy
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Ductal CA1) what % of all breast CA2) path characteristics of various subtypesa- Medullaryb-Tubularc- Mucinousd- Scirrhotice- which has worse prognosis3) rx
1) 85%2) a- smooth borders, inc lymphocytes, bizarre cellsb- small tubule formationsc-produces mucind/e- worse prognosis3) MRM or BCT with postop XRT
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Lobular CA1) what % of all breast CA2) T/F: increased risk of B/l, multifocal and multicentric disease3) what cell type confers worse prognosis4) rx
1) 10%2) true- doesn't form calcification, extensively infiltrative3) signet ring cells4) MRM or BCT with postop XRT
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Inflammatory CA1) what stage disease is it considered2) prognosis3) defining appearance characteristic4) rx
1) T4 disease2) very aggressive, median survival 36 mo3) dermal lymphatic invasion-> peau d'orange lymphedema appearance, warm and erythematous4) neoadjuvant chemo, then MRM, then adjuvant chemo-XRT
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Surgical options for breast CA1) when can you do subcutaneous mastectomy (simple mastectomy)2) when can you do breast-conserving therapy (lympectomy + ALND or SLNB) + post op XRT)-what size margin do you need3) what is removed in modified radical mastectomy4) absolute contraindications to breast conserving therapy5) relative C/I to breast conserving rx
1) not in CA, only DCIS, LCIS or prophylactic bc leaves 1-2% of breast tissue2) breast CA. need 1-cm margin3) removes all breast tissue including the nipple areolar complex and axillary node dissection (level I)4) 2+ primary tumors in separate quadrants, persistent positive margins after reasonable surgical attempt, pregnancy (can't do XRT- but if in 3rd trimester may be able to do and delay XRT to after birth), h/o XRT to area, diffuse malignant appearing microcalcifications5) scleroderma, SLE, large tumor in small breast, large/pendulous breasts
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Surgical options for breast CA1) when to do SLNB and how do you find nodes.2) complication of lymphazyrin blue dye3) when to do Axillary LND4) C/I to SLNB5) what to do if no LN found using radiotracer/dye in attempted SLNB6) what node levels do you take in ALND7) complications of MRM
1) malignant tumors >1cm without clinically positive nodes. inject lymphazyrin blue dye or radiotracer into tumor2) Type I hypersensitivity reaction3) clinically positive nodes4) pregnancy, multicentric disease, neoadjuvant therapy, clinically positive nodes, prior axillary urgery, inflammatory or locally advanced disease5) do formal ALND6) I and II7) infection, flap necrosis, seroma
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Complications of axillary lymph node disection (ALND)1) if early sudden postop swelling2) if swelling after 18months3) if inner arm and lateral chest wall hyperesthesia and how long to leave drains
infection, lymphedema, lymphangiosarcoma.Axillary vein thrombosis- early postop sudden swellinglymphatic fibrosis- swelling after 18monthsIntercostal brachiocutaneous nerve injry- hyperesthesia of inner arm and lateral chest wallleave drains until
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XRT for breast CA1) what dose to use2) complications of3) Contraindications to use4) when to use XRT after MASTECTOMY5) BCT with XRTa) what margins do you need before XRTb) local recurrence ratec) rx for local recurrence
1) 5000 rads2) edema, erythema, rib factures, pneumonia, ulceration, sarcoma, contralateral breast CA3) scleroderma (severe fibrosis and necrosis if give xRT), previous XRT would exceed recommended dose, SLE (relative), active rheumatoid arthritis (relative)4) >4nodes, skin or chest wall involved, positive margins, tumor >5cm (T3), extracapsular nodal invasion, inflammatory CA, fixed axillary nodes (N2) or internal mammary nodes (N3)5) a) 1cm negative marginsb) 10%, usually within first 2 years postop, need to restage recurrencec) need salvage MRM
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Chemotherapy for breast CA1) drug regimen2) what patients with positive nodes don't need chemo? And what can these pts get instead?3) which patients with negative nodes need chemo?4) which patients get hormonal therapy?5) T/F: both chemo and hormone therapy decrease recurrence and improve survival6) how much does tamoxifen decrease risk of breast ca and what are s/e's?
1) taxanes (docetaxel or paclitaxel), adriomycin and cyclophosphamide for 6-12 weeks2) Breast CA that has positive estrogen receptors in postmenopausal women is the only node positive disease that doesn't require chemo- give aromatase inhibitor (anastrozole) only.3)All pts with negative nodes and mass>1cm need chemo except if ER positive CA. for ER positive and postmenopausal give aromatase inhibitor (anastrozole) only or if premenopausal- tamoxifen only)*if
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Breast Cancer1) t/f: almost all women with recurrence die of disease2) increased recurrences and metastases occur with ____________.3) metastatic flare sx and rx4) occult breast CA- presentation and rx5) Paget's diseasea) presentation and dxb) what malignancy/premalignancy do these pts havec) rx
1) true2) large tumors, positive nodes, negative receptors, unfavorable subtypes3)sx- pain, swelling, erythema in metastatic areas.rx- XRT (esp good for bone mets)4) axillary mets with unknown primary. rx- MRM (70% have breast CA)5)a- scaly skin lesion on nipple, bx- paget's cellsb- DCIS or ductal CA in breastc- need MRM if cancer present, otherwise simple mastectomy including nipple-areolar complex with Paget's disease.
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Cystosarcoma phylloides1) what % are malignant and how to tell2) how do they spread3) path4) rx
1) 10%, based on mutations per hpf (>5-10)2) hematogenous (rare). No nodal mets3) like giant fibroadenoma (stromal and epithelial elecments/mesenchymal tissue). Can be large.4) WLE with negative margins. No ALND
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Stewart-Treves syndrome1) what causes it2) what malignancy is pressent3) classic presentation
1) chronic lymphedema 2/2 ALND2) lymphangiosarcoma3) dark purple nodule or lesion on arm 5-10years postop
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breast mass during pregnancy1) how to dx2) rx/dx for cyst3) rx/dx if solid4) If breast CA what is the rx ifa) 1st trimesterb) 2nd trimesterc) 3rd trimester5) effect on options for XRT
1) ultrasound first to avoid radiation. mammo and US don't work as well during pregnancy2) drain and send FNA for cytology3) perform core needle biopsy4) a and b- MRM; c-MRM or if late lumpectomy with ALND and postpartum XRT5) no XRT while pregnant, no breast feeding after delivery if getting XRT
