Surgery

Front 1

What are the anatomic borders used for mastectomy?

Back 1

2nd rib to 6th rib; lateral sternum to mid-axillary line; tail of Spence

Front 2

Regarding mastectomy, what are the levels of the axillary nodes, and in the case of sentinel lymph node positivity, how many nodes must be removed to make sure metastases are not missed?

Back 2

Ten lymph nodes are needed to make sure nodal metastases aren't missed. Axilla has three levels of nodes; level I is lateral to the pectoralis minor; level II is under, and level III is medial to the pectoralis minor muscle.

Front 3

Which vein is at risk of damage during a mastectomy?

Back 3

Axillary vein.

Front 4

What is the major risk of a mastectomy?

Back 4

Damage to adjacent nerves.

Front 5

Which nerves are at risk of damage during a mastectomy, and what are the results of damage?

Back 5

Intercostal brachial nerve; loss of sensation to the posteromedial aspect of the upper arm. Long thoracic nerve; winged scapula from loss of innervation to the serratus anterior. Thoracodorsal nerve; weakness of the latissimus dorsi muscle.

Front 6

What factors contribute to the risk of recurrence in a patient with ductal carcinoma of the breast?

Back 6

Size and grade of tumor; presence or absence of estrogen receptors; lymphatic or vascular invasion.

Front 7

What percentage of breast cancers are inherited?

Back 7

5-10%

Front 8

What's the difference between familial and hereditary breast cancer?

Back 8

Familial is when breast cancer has occurred in one or more first or second degree relatives. Hereditary is the same but occurs at a younger age, is frequently bilateral and associated with other tumors, and seems to be inherited in an autosomal dominant fashion.

Front 9

What are the BRCA genes and what is the significance of each?

Back 9

BRCA1: accounts for 40-50% of hereditary breast cancer; 80% of women with the gene develop breast cancer and 40% develop ovarian cancer. BRCA2: increased risk of breast cancer.

Front 10

What are symptoms of fibrocystic change of the breast?

Back 10

Breast nodules; mastalgia; nipple discharge.

Front 11

What does biopsy of fibrocystic change of the breast reveal?

Back 11

Cysts, fibrosis, sclerosing adenosis, or epithelial hyperplasia.

Front 12

What percentage of women with breast pain have cancer?

Back 12

5-10%

Front 13

What percentage of women with breast pain have cancer?

Back 13

0.5%

Front 14

What is the treatment of breast pain not associated with cancer?

Back 14

Analgesics and heat. For severe cases, hormone agonists or antagonists.

Front 15

What are potential causes of bloody discharge from the breast?

Back 15

Cancer, ductal papilloma, Paget's disease of the nipple, fibrocystic change.

Front 16

What is a ductal papilloma, and what are the concerns associated with it?

Back 16

A normally benign growth, but 0.5% are cancers; presence of a mass and of calcifications are more suggestive of cancer. Treatment is excisional biopsy.

Front 17

What is inflammatory carcinoma of the breast, and what is its classic presentation?

Back 17

The most aggressive form of breast cancer, accounting for 1-3% of cases. Classic presentation is rapidly enlarging, erythematous breast with skin edema resulting in dimpling (peau d'orange). Normally widely infiltrating so that no mass is palpable.

Front 18

What is the treatment of inflammatory carcinoma of the breast?

Back 18

NOT surgery, at least not as first. Patients who were treated with surgery had local recurrence of 50-80% and metastasis of 90%. Now initial treatment is multiagent chemotherapy followed by radiation, then surgery. This has improved five-year survival to 50%.

Front 19

What is the differential diagnosis for a neck mass?

Back 19

Thyroid versus non-thyroid; 50% originate from thyroid, other 50% is inflammatory, congenital, and non-thyroidal malignant. Malignant most common in adults, non in children. Congenital include thyroglossal duct and branchial cleft cysts.

Front 20

What are symptoms of thyrotoxicity?

Back 20

Tachycardia; arrhythmias; weight loss with increased appetite; emotional instability and insomnia; fatigue; weakness; amenorrhea; heat intolerance; bowel hyperactivity; hair loss; dry skin.

Front 21

Where does the thyroid originate during development?

Back 21

The medial and lateral components have different origins. The medial component originates from the foramen cecum in the tongue, which forms from the tuberculum impar at the base of the valate papillae. The lateral component, which is composed of the calcitonin-producing C cells, forms from the fourth pharyngeal pouch.

Front 22

What are the anatomical components of the thyroid gland and where are they located?

Back 22

Entire thyroid is located just below the cricoid cartilage. Two lobes are connected by an isthmus, and laterally the lobes extend up to the level of the middle of the thyroid cartilage. The pyramidal lobe is a diverticulum extending up from the isthmus. Lateral border is the carotid sheath and the sternocleidomastoid muscles. Strap muscles lie anterior to the thyroid. Parathyroid glands AND RECURRENT LARYNGEAL NERVES are on the posterior aspect of the lateral thyroid gland; nerves typically run in the tracheoesophageal groove.

Front 23

What are risk factors for thyroid malignancy?

Back 23

Especially low-dose radiation exposure, which was used in the mid-20th century to treat many benign conditions, is associated with well-differentiated thyroid cancer, especially papillary (90%). In a patient with a neck mass, age younger than 20 or greater than 60 and male sex are associated with malignancy. Patients with thyroid cancer often have a family history of thyroid disease, especially in female relatives.

Front 24

What are the MEN syndromes?

Back 24

I: parathyroid, pancreas, pituitary
II: parathyroid, pheochromocytoma, medullary thyroid carcinoma
III: pheo, medullary, neuromas of the tongue and conjunctiva, ganglioneuromas of Meissner's and Auerbach's plexi (and Marfanoid habitus)

Front 25

What are the types of thyroid malignancy?

Back 25

Papillary, follicular, medullary, and anaplastic

Front 26

What are the characteristics of papillary carcinoma of the thyroid?

Back 26

Well-differentiated; affects women more than men; tends to strike in the third and fourth decades of life; characterized by psammoma bodies histologically; slowest growing; spreads via lymphatics; 80% are multicentric but this is rarely clinically significant; metastasizes to lymph nodes in posterior triangle of the neck, in which case it's called "lateral aberrant thyroid." Mets can be treated with radioiodine. Follicular variant of papillary cancer is a hybrid of follicular and papillary carcinomas.

Front 27

What are the characteristics of follicular carcinoma of the thyroid?

Back 27

Well-differentiated, similar to papillary, but less multicentric and more likely to spread hematogenously to bone and lung. Mets are less likely to take up radioiodine, but when they do this is an appropriate therapy. The only way to distinguish follicular carcinoma from adenoma is by examining margins to rule out vascular or capsular invasion.

Front 28

What are the characteristics of medullary carcinoma of the thyroid?

Back 28

Calcitonin-producing and originating from C cells; elevated serum calcitonin and amyloid deposits in the tumor stroma are diagnostic; associated with MEN types II and III, and with mutations in the Ret proto-oncogene.

Front 29

What are the characteristics of anaplastic carcinoma of the thyroid?

Back 29

Account for less than 5% of thyroid cancers, occur later in life, extremely rapid and widespread growth; presentation is often with a painful and enlarged thyroid gland.

Front 30

What are indications for total thyroidectomy versus lobectomy in a patient with thyroid malignancy?

Back 30

Controversial; one large study has shown survival benefit for total thyroidectomy; generally surgeons agree that thyroidectomy is indicated with tumor is greater than 2 or 3 cm in diabeter.

Front 31

What are Hurthle cell carcinomas?

Back 31

Aggressive variants of follicular cell origin; not always malignant, and as with follicular carcinomas vascular or capsular invasion must be demonstrated, though some Hurthle cell carcinomas behave malignantly even without pathologic features. Size is important; less than 3cm more likely to be benign, greater than 6 more likely to be malignant.

Front 32

What is the treatment of medullary carcinoma of the thyroid?

Back 32

If limited to the gland, total thyroidectomy; if metastasized (to lymph nodes, usually), radical neck dissection. Metastasis indicated by persistently high calcitonin levels or by lymph node palpation. Almost 100% of patients with MEN types II and III will develop medullary carcinoma, and therefore prophylactic thyroidectomy is indicated at an early age for these patients.

Front 33

How is anaplastic carcinoma of the thyroid treated?

Back 33

Basically, it isn't. Extremely aggressive and associated with a very poor prognosis; thyroidectomy is of no benefit unless airway constriction is present. Chemo and radiation are available for palliation.

Front 34

What are the main steps of a thyroidectomy?

Back 34

General anesthesia; curvilinear transverse incision in Langer's line just below the cricoid cartilage over the thyroid isthmus, through skin, subcutaneous tissue, platysma, and cervical fascia overlying pretracheal muscles and anterior jugular veins. After subplastysmal flaps are developed, midline cervical fascia is opened, strap muscles (sternohyoid and sternothyroid) are separated, and thyroid is removed. If tumor infiltrates sternythyroid, the muscle is removed as well.