Lecture 10

Question 1

What are the surgical boundaries of the breast?

Answer 1

Sternal edge medially
Latissimus dorsi laterally
2nd rib superiorly
7th rib inferiorly
Ductal tissue may extend beyond boundaries

Question 2

What do the following nerves innervate?
1) Medial pectoral
2) Lateral pectoral

Answer 2

1) Innervates pectoralis minor & lateral border of pectoralis major
2) Innervates lower portion of pectoralis major

Question 3

What innervates latissimus dorsi muscle?

Answer 3

Thoracodorsal nerve

Question 4

Transection of what nerve can cause paralysis of latissimus dorsi muscle (weakened internal rotation & adduction of arm)?

Answer 4

Thoracodorsal nerve

Question 5

American Cancer Society (ACS) breast cancer guidelines apply to women at average risk; what are these guidelines?

Answer 5

Age 40-44: optional annual mammograms
Age 45-54: should get annual mammograms
Age 55 & older: can switch to every other year mammograms or continue annual mammograms (continued screening if in good health & life expectancy > 10 yrs)

Question 6

Who are clinical breast exams recommended for?

Answer 6

Clinical breast exams not recommended for average-risk at any age

Question 7

Core needle biopsy:
1) How is it done?
2) What imaging guidance is used?

Answer 7

1) Typically performed under local anesthesia
2) U/S, mammogram, x-ray, MRI (U/S preferred if lesion well-visualized)

Question 8

Fine needle aspiration:
1) What is it? Does it use imaging?
2) Is it sensitive for cancer?

Answer 8

1) Aspirate cells with a small needle to examine cytologically
Palpation or image guidance
2) Sensitivity lower than with CNB for cancer diagnosis
CNB sometimes required afterwards

Question 9

List some benign breast diseases

Answer 9

Cysts
Fibrocystic condition
Fibroadenoma
Hamartomas
Mondor disease
Inflammatory/infectious
Papillomas
Sclerosing lesions

Question 10

1) What are simple cysts?
2) What do they feel like?

Answer 10

1) Fluid-filled, epithelial-lined cavities generally in continuity with a duct
2) Firm, mobile, well-circumscribed

Question 11

Simple cysts:
1) What is used to confirm Dx and relieve Sxs of large cysts?
2) What is the risk of malignancy?
3) When should you do cytologic eval?

Answer 11

1) Aspiration (FNA)
2) Risk of malignancy <1% (cytology rarely indicated)
3) Cytologic eval rarely indicated UNLESS bloody aspirate, persistence following aspiration, rapid recurrence following aspiration

Question 12

Fibrocystic condition/disease:
1) What is it?
2) Is it a homogenous condition?

Answer 12

1) Spectrum of clinical, histologic, & mammographic findings
2) Range of clinical findings

Question 13

Fibrocystic condition/disease: Desr evaluation

Answer 13

U/S commonly used <30yo
Mammographic densities are common
Suspicious lesions should be biopsied (core needle biopsy preferred)

Question 14

Fibrocystic condition/disease: What are some causes/ RFs?

Answer 14

Estrogen thought to be causative factor
May be associated with trauma, alcohol, caffeine

Question 15

Fibroadenoma (epithelial & stromal elements):
1) What does it look/ feel like? Does it change?
2) Is Tx needed?

Answer 15

1) Usually round, rubbery, solitary, painless mass 1-5 cm diameter
Size increases with increased estrogen
2) Treatment usually not needed if diagnosis made by core needle biopsy

Question 16

What are Hamartomas?

Answer 16

Discrete, encapsulated, painless masses
May be found incidentally on screening mammography.

Question 17

Mondor Disease:
1) What is it?
2) Sxs?
3) Tx?

Answer 17

1) Self-limiting, variant of thrombophlebitis (superficial veins of the anterior chest wall and breast)
2) Localized pain with a tender, palpable subcutaneous cord or skin dimpling that becomes a painless, fibrous band often in lateral portion of breast
3) Often self-limited but anti-inflammatories and warm compresses help

Question 18

Mammary duct ectasia (dilation of lactiferous sinuses):
1) Who does it occur in?
2) Sxs? Imaging?
3) RF?
4) Tx?

Answer 18

1) Peri- & postmenopausal
2) Possible nipple inversion; greenish discharge (can vary)
-U/s required for all breast discharge
3) Cigarette smoking connection
4) Treatment depends on symptoms:
-Reassurance to symptomatic treatment
-If recurrent, may need to excise affected duct and surrounding inflammatory tissue

Question 19

Periductal mastitis:
1) Who does it occur in?
2) Sxs?

Answer 19

1) Non-lactational
Younger women, heavy smokers (90%)
2) Episodes of peri-areolar inflammation
Possible nipple retraction & purulent discharge

Question 20

Generalized mastitis:
1) What is it?
2) Sxs?
3) Tx?

Answer 20

1) Ascending infection from subareolar ducts; mc during lactation
2) Erythema & induration
3) Keep breastfeeding; frequently resolves with conservative measures and/or antibiotics (S. aureus)
Abscesses often amenable to aspiration
I&D: larger abscesses, diabetic patients

Question 21

Breast Abscess:
1) Medical Tx?
2) Surgical Tx?

Answer 21

1) Breast pump if breastfeeding
Antibiotics
Needle aspiration or open drainage, cultures
2) I&D: larger abscesses or diabetes
Resection of involved ducts if recurrent

Question 22

What are the 2 main types of papillomas?

Answer 22

Intraductal papillomas: polyps of epithelial lining of ducts
Subareolar papillomas: most common cause of bloody nipple discharge

Question 23

Papillomas:
1) How may they present?
2) Dx?
3) Tx?

Answer 23

1) Large papillomas may present as a mass
2) Mammogram, core needle bx
3) Surgical excision (1-4% risk of malignancy)

Question 24

Sclerosing lesions:
1) What are they? When are they most common?
2) What is one cause?
3) Why is it important to Dx?

Answer 24

1) Benign area of hardened tissue; in 30s, 40s
2) Sclerosing adenosis: proliferation of terminal ductules or acini & stromal elements
3) Increasing BC risk 2x

Question 25

Radial scar (complex sclerosing lesion) & fat necrosis: What should you do for these?

Answer 25

May mimic infiltrating cancer so often surgical Biopsy to determine whether benign or malignant since looks like cancer Elevated risk of subsequent breast cancer (treatment: surgical excision)

Question 26

List the risk factors for breast cancer

Answer 26

-Age (most significant) -Nulliparity -Age at first birth >30 -Age at menarche < age 12 & menopause > age 55 -Exogenous hormone use or exposure --cOCPs > 20% increased incidence after 5yrs -Alcohol consumption -Family history (BC or genetic mutations; Ashkenazi Jewish descent) -Hx of previous breast cancer -Hx of atypical epithelial hyperplasia (atypia) increases risk (ie ADH, ALH) -Prior chest irradiation (ie. from childhood lymphomas)

Question 27

Descr familial risks for breast cancer

Answer 27

1) 1st degree relative (mothers, sisters, daughters): factor of 2-3 increased risk 2) Multiple affected members with bilateral & early-onset BC: absolute risk to 1st degree relatives ~50%

Question 28

Descr BRCA1 & BRCA2

Answer 28

Rare: estimated frequency 1:1,000 Americans 1) BRCA1 mutations: ~40% of familial BC syndromes (also associated with 15-45% lifetime risk of ovarian cancer) 2) BRCA2 mutations: ~30% of familial BC -Associated with increased risk of BC in males

Question 29

Ductal Carcinoma in Situ (DCIS): 1) Sx? 2) What does it account for? 3) Why is surgery done?

Answer 29

1) May have nipple discharge or lump, usually unilat 2) ~1/4 of mammographically detected breast carcinomas (microcalcifications) 3) Prevent progression to invasive cancer through mastectomy, partial mastectomy (breast conserving therapy), or partial mastectomy

Question 30

Lobular carcinoma in situ (LCIS): 1) What is it? 2) Is it pre malignant? Explain

Answer 30

1) Neoplastic cells distend breast acini 2) Generally, not considered pre-invasive lesion; rather a marker of increased risk for invasive BC Positive risk factor for invasive BC in affected or contralateral breast (1% per year)

Question 31

Lobular Carcinoma in situ (LCIS): How do you Tx?

Answer 31

CNB then... 1) Observation: biannual clinical breast exams, annual mammograms 2) Alternative option: bilateral prophylactic mastectomies *if strong FHx breast or ovarian CA, BRCA1 or BRCA2 mutation 3) +/- prevention therapy with Tamoxifen

Question 32

Invasive Breast Cancer: 1) What is it? 2) Where does it originate?

Answer 32

1) Penetration of malignant cells through basement membrane 2) Lobular or ductal in origin

Question 33

Breast Cancer Spread: 1) How does it spread? 2) How common is AN involvement? 3) What are some common sites of distant mets?

Answer 33

1) May spread via direct extension through breast parenchyma and hematogenous to remote sites 2) ~50% of patients with palpable BC have AN involvement 3) Bones (40-50%), lung (20%), followed by liver, brain and spine

Question 34

American Society of Clinical Oncology & College of American Pathologists recommendation for invasive breast cancers is?

Answer 34

1) Estrogen receptor (ER), progesterone receptor (PR), HER2 analysis should be performed routinely in all invasive breast cancers -Used to select patients for endocrine therapy (adjuvant treatment) 2) Sentinel node biopsy (SNB) as alternative to axillary dissection (patients without evidence of axillary LN metastasis)

Question 35

Invasive Breast Cancer surgical options: 1) Describe Modified radical mastectomy (MRM) 2) Describe Total or simple mastectomy

Answer 35

1) Standard; removes breast tissue & axillary nodes but spares pectoralis muscles (replaced radical mastectomy) 2) Pectoralis-sparing procedure without axillary lymphadenectomy

Question 36

Invasive Breast Cancer surgical options: 1) What is Partial mastectomy (lumpectomy) with radiation therapy? 2) What prevents this from being used?

Answer 36

1) Aka breast-conserving therapy (BCT); goal of BCT: completely excise lesion +radiation after partial mastectomy (5-7wks) 2) Contraindications to radiation therapy prevent breast conservation

Question 37

Breast reconstruction 1) Goals? 2) Descr what must be done when reconstruction is delayed

Answer 37

1) Recreate natural-appearing breast mound matching opposite breast size, contour, & degree of ptosis 2) Occurs after undergoing mastectomy, requires tissue-expander

Question 38

Define autologous and alloplastic breast reconstruction

Answer 38

Autologous: uses patient’s own tissue Alloplastic: uses implants

Question 39

Autologous breast reconstruction: What are potential donor sites?

Answer 39

Lower abdomen, buttocks, back

Question 40

Autologous breast reconstruction: What are 4 different methods/ types?

Answer 40

1) Pedicled TRAM (transverse rectus abdominus myocutaneous) flap 2) Free TRAM flap 3) DIEP (deep inferior epigastric perforator) flap 4) SIEP (superficial epigastric perforator) flap

Question 41

Describe TRAM (transverse rectus abdominus myocutaneous) flap reconstruction

Answer 41

Sacrifices abdominal muscles Pedicled vs Free

Question 42

Descr the 2 stages of Alloplastic breast reconstruction (implants)

Answer 42

1) 1st stage: placement of inflatable tissue expander (6-8wks) Recruits additional skin and soft tissue 2) 2nd stage: expander replaced with permanent prosthesis (~3mos total)

Question 43

Describe Skin-sparing Mastectomy

Answer 43

Removes all breast tissue, the nipple-areola complex and scars from any previous biopsies Immediate autologous breast reconstruction Peri-areolar incision Skin envelope of the breast kept intact during the procedure

Question 44

Tamoxifen: 1) How long does Tx last? 2) What are the side effects? 3) BBBs?

Answer 44

1) 5 years of treatment = 49% reduction in the risk of invasive breast carcinoma overall *Current recommendation is 10 years of treatment 2)Increased incidence of endometrial cancer & thromboembolic events (DVT, PE), hot flashes, vaginal discharge, cataracts, mood swings 3) Uterine malignancies, pulmonary embolism, and stroke in patients with high risk of cancer or who have DCIS

Question 45

Descr the Recommendations for use of adjuvant therapy in breast cancer

Answer 45

Candidates are selected based on genetic analysis of tumor Low risk (not candidates): negative ANs & tumor <1 cm, nuclear grade 1; or 1-2 cm ER+ tumor with low proliferation index

Question 46

List the male BC risk factors

Answer 46

1) Strongest: Klinefelter syndrome (47,XXY) 2) Others: FHx breast or ovarian CA BRCA2 mutation h/o undescended testes Chronic liver disorders (ie, cirrhosis)

Question 47

What are some Features suggestive of malignancy of a thyroid nodule?

Answer 47

New nodule Rapid increase in size of existing nodule Painful nodule

Question 48

Thyroid Nodule Work-Up: 1) Why is thyroid US done? 2) What should you do if low TSH?

Answer 48

1) To document # nodules, suspicious?, lymph nodes affected? 2) Radioiodine (radionucleide) scanning to eval for hyperfunctioning (hot/functioning) nodules (rarely associated with malignancy) >Order FT4, T3

Question 49

If elevated Sr TSH associated with elevated risk of malignancy in nodule, what should you do?

Answer 49

If high-risk nodule, recommend FNA: >5mm in high-risk patients, nodules with suspicious sonographic features such as microcalcifications, irregular margins, moderate-risk nodules > 1cm, and low risk nodules >1.5-2cm

Question 50

Descr papillary thyroid carcinoma

Answer 50

80-90% in countries with sufficient iodine intake; most common overall: -Psammoma bodies (laminated calcified bodies in ~1/2 specimens) -Young adults, slow growing, solitary nodule -Spread via lymphatics to regional LNs (30-40% at presentation), slow growing -95% 10 year survival rate

Question 51

Descr follicular thyroid carcinoma

Answer 51

10% of thyroid malignancies in areas where goiter not endemic; 90% 10yr survival rate: 1) Frequent vascular invasion 2) Occurs later in life compared to papillary

Question 52

List and describe the 4 less common types of thyroid carcinoma

Answer 52

1) Hurthle cell carcinoma: considered a clinical variant of follicular carcinoma (85% 10 yr survival rate) 2) Insular carcinoma 3) Medullary thyroid carcinoma (5-10%, not associated with radiation exposure, associated with a familial syndrome in 25% of cases) – MEN2A/MEN 2B 4) Anaplastic thyroid cancer (1-2%, one of the most aggressive and lethal malignancies, appears later in life)

Question 53

Descr thyroid nodule resection

Answer 53

Thyroid lobectomy if <1cm (less aggressive, early stages) 1-4cm- lobectomy vs thyroidectomy Near-total or total thyroidectomy if carcinoma (>4cm)

Question 54

Radioiodine Therapy (RAI) after surgical resection of a thyroid nodule should be done when?

Answer 54

For well-differentiated carcinomas: Known distant mets, extrathyroidal extension, and tumors >4cm in size, poor surgical candidates

Question 55

The principle indications for surgical removal of nodular goiter include?

Answer 55

-Suspicion of or documented cancer -Inability to rule out cancer in suspicious nodule -Compressive symptoms -Hyperthyroidism -Substernal extension -Cosmetic deformity

Question 56

Toxic Adenoma: 1) What is it? 2) What causes it?

Answer 56

1) Benign thyroid nodule, secretes thyroid hormones and causes hyperthyroidism 2) Result of focal and/or diffuse hyperplasia of thyroid follicular cells

Question 57

Toxic Adenoma: Describe Tx based on size adenoma and age of pt

Answer 57

1) If smaller, may be managed with antithyroid meds and RAI 2) If larger, may require higher doses (which may lead to hypothyroidism) 3) If younger and with large nodule, surgery recommended

Question 58

Pituitary Adenoma: 1) Descr the average case 2) What are the 2 main types?

Answer 58

1) Most are benign and arise from the anterior lobe of the pituitary 2) Secretory vs nonsecretory tumors Most nonfunctional (nonsecretory)

Question 59

Descr secretory pituitary adenomas

Answer 59

often have vague complaints or asymptomatic If secreting prolactin, see amenorrhea, galactorrhea 2/2 overproduction of prolactin, or infertility If secreting GH, may cause acromegaly If secreting ACTH, may cause Cushing syndrome If compress optic chiasm, may cause VF defects (bitemporal hemianopsia)

Question 60

Descr the mainstay of pituitary adenoma Tx

Answer 60

Resection is mainstay of treatment for most kinds of pituitary adenomas Except prolactin secreting adenomas for which there is effective medical therapy (dopamine agonists) Except asx nonfunctioning adenomas

Question 61

What does successful pituitary adenoma resection req?

Answer 61

Navigate to the sella Visualize the tumor through a relatively narrow corridor Remove the tumor as completely as possible Minimize damage to the surrounding structures, including the normal pituitary gland + radiation therapy

Question 62

1) Define primary hyperparathyroidism 2) What should preop assessment incl?

Answer 62

1) excess PTH secretion most commonly due to parathyroid adenoma (83%), multiple adenomas, hyperplasia, or carcinoma (1%) 2) Labs: serum Calcium (expect high), PTH (increased if primary) Imaging: U/S, CT, MRI Localization studies: Sestamibi 99mTc

Question 63

What is recommended in patients with primary hyperparathyroidism and clinical symptoms?

Answer 63

Surgical intervention (parathyroidectomy) no data to support observation

Question 64

What are some Options for parathyroid hyperplasia (secondary)?

Answer 64

Subtotal parathyroidectomy (removal of 3.5 of 4 gland) Primary Hyperthyroidism: parathyroidectomy Total parathyroidectomy

Question 65

What are some possible (rare) complications with Parathyroid Surgery?

Answer 65

Persistent disease (5%; usually a missed adenoma); Recurrent disease Bleeding & neck hematoma (<1%) Injury to RLN (recurrent laryngeal nerve) Permanent hypoparathyroidism/ hypocalcemia

Question 66

Indications for adrenal surgery result from hypersecretory states, such as? How are these confirmed?

Answer 66

1) Surgery performed for hyperaldosteronism (primary= Conn syndrome), pheochromocytoma, hypercortisolism (Cushing disease or Cushing syndrome), & adrenocortical carcinoma 2) Confirmed with ACTH (adrenocorticotropic hormone) or renin level If ACTH or renin level is suppressed but hormone excretion of cortisone, aldosterone, etc. is excessive, an adrenal cause is confirmed

Question 67

Adrenal Glands: 1) Preop imaging? 2) What type of surgery? 3) What are adrenal incidentalomas?

Answer 67

1) Tumors identified preoperatively with CT or MRI 2) Almost all adrenal tumors can be removed laparoscopically (esp after imaging) Open adrenalectomy when >8-10cm 3) Asymptomatic adrenal masses found “incidentally” on CT, MRI

Question 68

Preoperative medical treatment for pheochromocytomas: 1) When is it started? 2) What meds are started?

Answer 68

1) As soon as Dxd 2) a) Phenoxybenzamine (alpha blocker): Once alpha blockade achieved, may add beta blocker if tachycardia present *Must initiate alpha blockade prior to beta blocker use Otherwise, malignant htn, cardiac failure b) Also start metyrosine which blocks the rate-limiting step in catecholamine production preoperatively Decreases BP fluctuations occurring with manipulation of tumor during resection

Question 69

After localization with CT or MRI, definitive treatment for pheochromocytomas is?

Answer 69

excision (laproscopic adrenalectomy if <5-6cm; open if larger)

Question 70

Multiple endocrine neoplasia: 1) What is it? 2) Types? 3) MC manifestation?

Answer 70

1) Inherited condition of propensity to develop multiple endocrine tumors 2) MEN type I, MEN type II, MEN type III 3) Multiple parathyroid tumors causing hyperparathyroidism = most common manifestation

Question 71

MEN 1: 1) What causes it? 2) Features? 3) Dx?

Answer 71

1) Genetic defect in chromosome 11 Occurs in nearly all patients by age 50 2) primary hyperparathyroidism, pituitary adenomas, pancreatic islet cell/GI tumors (ie, ZES, insulinomas), other tumors (ie, carcinoid, cutaneous tumors) 3) Clinical: Occurrence of >2 primary MEN1 tumor types (parathyroid gland, anterior pituitary, and enteropancreatic) Genetic testing for FHx (menin gene mutation on chromosome 11)

Question 72

MEN 1 Parathyroid tumors (hyperparathyroidism): 1) Definitive Tx? 2) What if asymptomatic? (or minimally symptomatic) 3) What if symptomatic?

Answer 72

1) Surgical removal of overactive parathyroid 2) Surgery vs no therapy: Some opt for surgery in young patients due to life expectancy Some defer surgery (fewer lifetime surgeries due to recurrence) 3) Surgery Hypercalcemia, nephrolithiasis, evidence of bone disease Also for severe PUD secondary to gastrinomas (ZES)

Question 73

MEN Type IIA (or MEN 2): 1) What is it? 2) What causes it? 3) What are the variants?

Answer 73

1) Autosomal dominant, characterized by medullary thyroid cancer (MTC), pheochromocytoma, & primary parathyroid hyperplasia 2) Genetic defect: RET proto-oncogene on chromosome 10 3) 4 variants of MEN 2A: Classical, with cutaneous lichen amyloidosis (CLA), with Hirschsprung disease (HD), & familial medullary thyroid cancer (FMTC)

Question 74

How is MEN Type IIA (or MEN 2) diagnosed?

Answer 74

based on presence of classical clinical features, family history, & genetic testing

Question 75

MEN Type III (formerly MEN IIB): 1) Inheritance pattern? 2) Characteristics? 3) Cause?

Answer 75

1) Autosomal dominant 2) Characterized by mucosal neuromas w bumpy, enlarge lips and tongue (90% of cases), MTC and pheochromocytoma but not hyperparathyroidism 3) Genetic defect of RET proto-oncogene on chromosome 10

Question 76

MEN Type III (formerly MEN IIB): 1) Who should you suspect in? 2) Dx?

Answer 76

1) Any patient with medullary thyroid cancer (MTC) or pheochromocytoma 2) Based on presence of classical clinical features (delayed puberty), family history, & genetic testing

Question 77

How do you Tx Primary hyperparathyroidism (MEN 2A only)?

Answer 77

Asymptomatic: defer surgery, long-term monitoring (hypercalcemia, renal disease, bone loss) Symptomatic (nephrolithiasis, hypercalcemia): parathyroid surgery (only definitive therapy)