Superficial lesions Flashcards
What is a lipoma?
Benign tumour of mature fat cells
Do lipomas undergo malignant change?
No, or very rarely.
Liposarcomas arise de novo
How to treat a lipoma?
- watch and wait
- remove if patient choice, painful, bad cosmesis.
- need to remove capsule or recurs?
Lipomas variants
- angiolipomas: prominent vasc component
- hibernomas: brown fat cells
- Bannayan-Zonana syndrome: multiple lipomas, macrocephaly, haemangiomas
Dercum’s disease
aka Adiposis dolorosa: multiple painful lipomas associated with peripheral neuropathy
Liposarcoma classficiation
1 - well-differentiated
2 - myxoid and round cell (poor-dif)
3 - pleomorphic
What are the complications of a sebaceous cyst?
- infection
- ulceration
- calcification (trichilemmal cyst)
- sebaceous horn formation
- malignant change
Sebaceous cyst treatment
- watch and wait if small, asymptomatic
- elliptical skin excision including capsule to prevent recurrence
Different histological subtypes of sebaceous cyst?
- Epidermal: from infundibular portion of hair follicles
- Trichilemmal: from hair follicle epithelium, more common on scalp
Gardner’s syndrome
- multiple epidermal cysts
- adenomatous polyposis of colon
- multiple skull osteomata
- desmoid tumours
What is a ganglion?
Cystic swelling related to a synovial lined cavity (joint or tendon sheath).
Ganglion differential
- bursae
- cystic protrusions from arthritic joints
- benign giant cell tumours of flexor sheath
- rarely, malignant e.g. synovial sarcoma
Ganglion treatment
- watch and wait
- aspiration + 3 weeks immobilisation
- complete excision including neck at origin
Complications of surgical ganglion treatment
- wound complications e.g. scar, haematoma, infection
- recurrence
- damage to adjacent neurovascular structures
Neck triangle borders
- anterior: anterior border of sternocleidomastoid, midline, ramus of mandible
- posterior: anterior border of trapezius, clavicle, posterior border of sternocleidomastoid
Midline neck lumps DDx
- Solid: thyroid swelling
- Cystic: thyroglossal cyst
Anterior triangle lump DDx
- solid: lymphadenopathy or carotid chemodectoma
- cystic: branchial cyst, cold abscess (TB)
Posterior triangle lump DDx
- solid: lymphadenopathy
- cystic: pharyngeal pouch or cystic hygroma
What is a sternomastoid tumour?
an ischaemic contracture of a segment of muscle seen in first 1-2 weeks of life following complicated birth. Usually resolves over 4-6 months
Cervical lymphadenopathy causes
L - lymphoma, leukaemia
I - infection (tonsillitis, TB, CMV, EBV, HIV)
S - sarcoidosis
T - tumours, primary + secondary
Cervical lymphadenopathy investigations
Bloods - FBC, ESR, TFTs, ACE, monospot/paul-bunnell
Radiological - USS, CT, MRI
Histological - FNAC, excision biopsy
Cervical lymphadenopathy FNAC results
- if SCC or TB, don’t perform excision biopsy
- if adenocarcinoma, lymphoma or other infection/inflammatory cause, do excision biopsy
What is the arterial supply to thyroid gland?
- superior thyroid artery from external carotid
- inferior thyroid artery from thyrocervical trunk from subclavian artery
- these two anastamose behind the thyroid gland
What do you know about solitary thyroid nodules?
- F:M = 4:1
- commonest 40s-50s
- 10% malignant in middle-aged
- 50% malignant in young and elderly
- FNAC most important investigation
Investigation of solitary thyroid nodule
Triple assessment
- clinical hx and exam
- USS
- FNAC
What do you know about thyroid adenomas?
- most follicular adenomas
- 2-4cm encapsulated
- indistinguishable from carcinomas on FNAC
- need surgical excision to confirm diagnosis
Thyroid malignancy
- Papillary - 70%, commonest in young, lymphatic spread
- Follicular - 15%, mean age 50, haematological spread
- Medullary - 8%, parafollicular C cells, calcitonin, 10% MEN2a/b
- Anaplastic - 5%, elderly
- Lymphoma - 2%
Multiple endocrine neoplasia types
All Autosomal dominant
MEN 1 - pancreatic islet cell tumour, pituitary adenoma, primary hyperparathyroidism
MEN 2a - phaeo, medullary thyroid Ca, primary hyperparathyroidism
MEN 2b - phaeo, medullary thyroid Ca
Feature of multinodular goitre
- progression from smooth goitre to nodular
- middle-aged women
- family history
- malignant change in 5%
- mild hyperthyroidism (Plummer’s syndrome) or euthryoid
- no eye signs
MNG management
- often no intervention
- investigate prominent nodule or if malignancy features
- TFTs, USS + FNAC, CX
- Remove goitrogens (cabbage)
- Low dose thyroxine causes regression in 50-70%
- If thyrotoxic, treat as Graves
- radioiodine if unfit for surgery
- bilateral subtotal thyroidectomy
- total thyroidectomy + thyroxine reduces maligancy risk (best option)
Indications for MNG surgery
- Mechanical - obstructive symptoms
- Malignancy
- Medical treatment failure - thyrotoxic
- Mediastinal extension - unable to FNAC or monitor clinically
- Marred beauty - cosmetic
Difference between TMNG and Graves’
TMNG - older, nodular, no eye signs, AF in 40%, no AI association
Graves’ - younger, diffuse, eyes signs, AF uncommon, associated AI diseases
Causes of diffusely enlarged thyroid gland
- simple colloid goitre
- Graves’ disease
- thyroiditis (Hashimoto’s, de Quervain’s, Riedel’s)
What do you know about simple colloid goitres?
- commonest thyroid abnormality
- physiological hyperplasia or defection hormone production
- Causes: iodine deficiency, puberty, pregnancy, goitrogens, drugs (lithium, amiodarone), congenital defects (rare)
Graves’ treatment
- Medical: anti-thyroid drugs (carbimazole, propythiouracil) inhibit thyroid peroxidase, beta-blockers (propanolol) provide symptomatic relief
- Radioiodine: Absolute CI = pregnancy, lactation. Risks = early hyperthyroidism, late hypothyroidism, late hyperparathyroidism
- Surgery: Bilateral subtotal thyroidectomy or total. Good for relapse, pregnant patients, those wanting to get pregnant in next 4 years, large goitres
Thyroidectomy complications
General or specific
- Immediate: haemorrhage + airway obstruction, hoarseness (recurrent laryngeal nerve damage), hyperthyroidism (thyroid storm)
- Early: infection, hypoparathryoidism leading to hypocalcaemia
- Late: Recurrence, hypothyroidism, hypertrophic scaring