Mastectomy and axillary node clearance Wide local excision ...

A 43 year old lady is diagnosed as having a malignant lesion in the inferior aspect of her left breast. There is palpable axillary lymphadenopathy. What is the most appropriate course of action?

Mastectomy and axillary node clearance

Wide local excision and axillary node clearance

Wide local excision and sentinel lymph node biopsy

Image guided fine needle aspiration of the axillary nodes

CT scanning of the chest, abdomen and pelvis

Where axillary nodal involvement is suspected from the outset it is important to establish whether this is the case prior to surgery. This is because, if axillary metastatic disease is present then the correct management would be an axillary node clearance and this is irrespective of the surgical plans for the breast primary. In the case of breast cancer, image guided FNAC is acceptable as it is accurate and if carcinoma cells are identified at FNA then axillary node clearance can be performed. If FNAC is negative then a sentinel node biopsy should accompany excision of the primary tumour. Where the axilla is clinically clear on palpation and imaging then a sentinel lymph node biopsy should accompany excision of the primary tumour. Please rate this question:

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Management of the axilla- breast cancer

Lymph node stage

Accurate staging of the axilla is an essential component of breast cancer management. Involvement of the axillary nodes has an adverse effect on prognosis with 10 year survival reduced from 75% to 25%[1]. Involvement of level 3 nodes carries the worst prognosis[2]. Historically, management of the axilla ranged from limited level 1 axillary node excision through to full level 3 axillary nodal clearances. Attempts to mimimise the morbidity of axillary node clearance led to targeted operations including axillary nodal sampling and sentinel lymph node biopsy. The focus on sentinel lymph node biopsy has led to more detailed pathological analysis of excised lymph nodes (e.g. using immunohistochemistry). This has led to increasing focus on the develop of axillary nodal micrometastasis. The presence of micrometastasis and its impact on survival is debated. In some studies it seems to confer an increased risk of locoregional recurrence [3] and a reduction of disease free survival [4], whilst in others it shows no overall impact[5]. It is important to distinguish between micrometastasis and isolated tumour cells, as the latter do not have an adverse impact on prognosis[6]. The need for definitive treatment of the axilla in women with positive sentinel nodes

http://emrcs.com/question/question.php?q=0#left-panel

was addressed by the ASCOG Z0011trial. In this trial women were randomised to either undergo axillary node clearance or observation, groups were adjusted for other prognostic factors and treatments. The investigators found no survival benefit in routinely undertaking axillary node clearance where axillary nodal disease was limited in its extent. Regardless of the options in women with a low risk axilla, those individuals who have overt evidence of axillary nodal involvement either through positive SLNB or preoperative USS and FNA, should still receive axillary clearance as a standard of care. References

1. Carter, C.L., C. Allen, and D.E. Henson, Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer, 1989. 63(1): p. 181-7. 2. Clark, G.M. Integrating prognostic factors. Breast Cancer Res Treat, 1992. 22(3): p. 187-91. 3. Lupe, K., et al. Ten-year locoregional recurrence risks in women with nodal micrometastatic breast cancer staged with axillary dissection. Int J Radiat Oncol Biol Phys, 2011. 81(5): 681-8. 4. Park, D. et al. The prognostic impact of occult nodal metastasis in early breast carcinoma. Breast Cancer Res Treat, 2009. 118(1): 57-66. 5. Galimberti, V., et al. Positive axillary sentinel lymph node: is axillary dissection always necessary? Breast, 2011. 20 Suppl 3: S96-8. 6. Ahmad, N. and J. Park, Defining Semantic Structure Features for Content-Based Visual Object Class Recognition. Journal of Imaging Science and Technology, 2011. 55(2).

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Theme: Breast conditions

A. Mondors disease

B. Duct ectasia

C. Periductal mastitis

D. Lactational breast abscess

E. Fibroadenoma

F. Breast cyst

G. Intraductal papilloma

H. Atypical ductal hyperplasia

I. Radial scar Please select the most likely underlying diagnosis for the scenario given. Each option may be used once, more than once or not at all.

2. A 20 year old lady presents with a mobile lump in the upper outer aspect of her right breast.

On examination she has a firm mobile mass in the upper outer quadrant of her right breast.

You answered Mondors disease

The correct answer is Fibroadenoma

Fibroadenomas account for 60% of discrete breast lesions in the 18-25 year age group. They

are mobile lesions. Core biopsy should be performed in lesions measuring more than 4cm in

diameter.

3. A 55 year old women presents with nipple discharge. On examination she has a slit like

retraction of the nipple in the centre of this area is a small amount of cheese like material.

No discrete mass lesion is palpable in the underlying breast.


The correct answer is Duct ectasia

Duct ectasia is a common alteration in the breast that occurs with aging. As the ducts

shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of

cheese like discharge may occur.

4. A 48 year old lady presents with discomfort in the right breast. On examination she has a

discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is

performed and a "halo sign" is seen by the radiologist.


The correct answer is Breast cyst

Lesions such as breast cysts compress the underlying fat and produce a radiolucent area

(halo sign). If symptomatic, these cysts should be aspirated.

Theme January 2014 exam

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Abberations of normal development and involution- breast

Fibroadenoma Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group, fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome. Breast cysts Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a "halo appearance" on mammography. Ultrasound will confirm the fluid filled nature of the cyst. Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone. Duct ectasia As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.

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A 43 year old lady has recently undergone a wide local excision and sentinel lymph node biopsy for

carcinoma of the breast. Of the factors listed below, which will provide the most important prognostic

information?

Mitotic number

Grade

Nodal status

Size

Oestrogen receptor status

Nodal status is the single most important prognostic factor in breast cancer.

Theme from April 2012 Exam

Theme from January 2013 Exam


Nodal status is important because it serves as a marker of tumour metastatic potential. This

translates to survival advantages of up to 40% at five years. Both grade and size are of secondary

importance as they both less concerning in the absence of nodal involvement.



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Breast cancer

Commoner in the older age group Invasive ductal carcinomas are the most common type. Some may arise as a result

of ductal carcinoma in situ (DCIS). There are associated carcinomas of special type e.g. Tubular that may carry better prognosis.


The pathological assessment involves assessment of the tumour and lymph nodes, sentinel lymph node biopsy is often used to minimise the morbidity of an axillary dissection.

Treatment, typically this is either wide local excision or mastectomy. There are many sub types of both of these that fall outside of the MRCS. Some key rules to bear in mind.

Whatever operation is contemplated the final cosmetic outcome does have a bearing. A woman with small breasts and a large tumour will tend to fare better with mastectomy, even if clear pathological and clinical margins can be obtained. Conversely a women with larger breasts may be able to undergo breast conserving surgery even with a relatively large primary lesion (NB tumours >4cm used to attract recommendation for mastectomy). For screen detected and impalpable tumour image guidance will be necessary.

Reconstruction is always an option following any resectional procedure. However, its exact type must be tailored to age and co-morbidities of the patient. The main operations in common use include latissimus dorsi myocutaneous flap and sub pectoral implants. Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps.

Surgical options

Mastectomy vs Wide local excision

Mastectomy Wide Local Excision

Multifocal tumour Solitary lesion

Central tumour Peripheral tumour

Large lesion in small breast Small lesion in large breast

DCIS >4cm DCIS <4cm

Patient Choice Patient choice

Central lesions may be managed using breast conserving surgery where an acceptable cosmetic

result may be obtained, this is rarely the case in small breasts

A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast

conserving surgery

Image sourced from Wikipedia

Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less

at 5 years [1].

Nottingham Prognostic Index

The Nottingham Prognostic Index can be used to give an indication of survival. In this system the

tumour size is weighted less heavily than other major prognostic parameters.

Calculation of NPI

Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).

Score Lymph nodes involved Grade

1 0 1

2 1-3 2

3 >3 3

http://en.wikipedia.org/wiki/Mastectomy

http://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb069b.jpg


Prognosis

Score Percentage 5 year survival

2.0 to 2.4 93%

2.5 to 3.4 85%

3.5 to 5.4 70%

>5.4 50%

This data was originally published in 1992. It should be emphasised that other factors such as

vascular invasion and receptor status also impact on survival and are not included in this data and

account for varying prognoses often cited in the literature.

References

Surgical guidelines for the management of breast cancer, Association of Breast Surgery at BASO

2009, Eur J Surg Oncol (2009), doi:10.1016/j.ejso.2009.01.008

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Theme: Management of nipple discharge

A. Prescribe danazol

B. Microdochectomy

C. Total duct excision

D. Cytology of duct fluid

E. Core biopsy

F. Prescribe co-amoxiclav

G. Reassure and discharge

H. Mastectomy What is the best management for each nipple discharge presentation? Each option may be used once, more than once or not at all.

6. A 23 year old women with greenish nipple discharge on one occasion. Clinical examination

of the breast is normal. Ultrasound report is U1.

You answered Prescribe danazol

The correct answer is Reassure and discharge


This is likely to be simple duct ectasia and U1 (normal USS) coupled with normal

examination would favor discharge from clinic. Mammography is generally unhelpful in

this age group

7. A 43 year old women has had recurrent episodes of periductal mastitis. She has received

multiple courses of antibiotics and is troubled by persisting green nipple discharge. Clinical

examination reveals green nipple discharge, but no discrete lump. Imaging with

mammography and ultrasound is reassuring (U2, M2)


The correct answer is Total duct excision

This woman has troublesome duct ectasia and total duct excision is warranted.

8. A 55 year old women complains of nipple discharge. This was blood stained on one

occasion. But not subsequently. Clinical examination shows clear fluid but no discrete

lump. Imaging with ultrasound and mammography is normal.


The correct answer is Microdochectomy

Although this is likely to be benign disease, her age coupled with an episode of blood

stained discharge would attract a recommendation for microdochectomy. She may have an

intraductal papilloma. But the concern would be DCIS.



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Nipple discharge

Causes of nipple discharge

Physiological During breast feeding

Galactorrhoea Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated

Hyperprolactinaemia Commonest type of pituitary tumour

Microadenomas <1cm in diameter

Macroadenomas >1cm in diameter

Pressure on optic chiasm may cause bitemporal hemianopia

Mammary duct

ectasia

Dilatation breast ducts.

Most common in menopausal women

Discharge typically thick and green in colour

Most common in smokers

Carcinoma Often blood stained

May be underlying mass or axillary lymphadenopathy

Intraductal papilloma Commoner in younger patients

May cause blood stained discharge

There is usually no palpable lump

Assessment of patients


Examine breast and determine whether there is mass lesion present All mass lesions should undergo Triple assessment.

Reporting of investigations Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below:

1 No abnormality

2 Abnormality with benign features

3 Indeterminate probably benign

4 Indeterminate probably malignant

5 Malignant

Management of non malignant nipple discharge

Exclude endocrine disease

Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

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Theme: Breast disease

A. Ductal carcinoma in situ

B. Lobular carcinoma in situ

C. Invasive ductal carcinoma

D. Invasive lobular carcinoma

E. Inflammatory carcinoma

F. Phyllodes tumour

G. Paget's disease of the nipple

H. Fibroadenoma

I. Mucinous breast carcinoma From the list please select the most likely diagnosis for the scenario given. Each diagnosis may be used once, more than once or not at all.

9. A 32 year old Indian lady presents with breast lump. She has a 4 month old child.

Clinically she has jaundice and there is erythema of the left breast.

You answered Ductal carcinoma in situ

The correct answer is Inflammatory carcinoma

Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is

more resistant to adjuvent treatments than other types of breast cancer. Often occurs in

pregnancy or lactation.

10. A 72 year old female presents with a painless breast lump. Clinically she has a 4cm

diameter irregular breast mass, with no other palpable masses.


The correct answer is Invasive ductal carcinoma

A post menopausal woman is more likely to have a ductal carcinoma and they tend to

occur at a single focus within the breast.

11. A 72 year old woman presents with 2 breast lumps. She has a history of breast cancer in

the opposite breast 5 years ago.


The correct answer is Invasive lobular carcinoma

This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and

the history of previous breast cancer in the opposite breast.



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Breast cancer







Surgical options Mastectomy vs Wide local excision







DCIS >4cm DCIS <4cm



result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast

conserving surgery


Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years [1]. Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).





1 0 1

2 1-3 2

3 >3 3

Prognosis


2.0 to 2.4 93%

2.5 to 3.4 85%

3.5 to 5.4 70%

>5.4 50%

This data was originally published in 1992. It should be emphasised that other factors such as vascular invasion and receptor status also impact on survival and are not included in this data and account for varying prognoses often cited in the literature. References Surgical guidelines for the management of breast cancer, Association of Breast Surgery at BASO 2009, Eur J Surg Oncol (2009), doi:10.1016/j.ejso.2009.01.008

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A 45 year old man is referred to the breast clinic with gynaecomastia. He takes the drugs listed below. Which is least likely to be the cause of his symptoms?

Spironolactone

Carbimazole

Chlorpromazine

Cimetidine

Methyldopa

Mnemonic for drugs causing gynaecomastia: DISCO D igitalis I soniazid S pironolactone C imetidine O estrogen Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE M etoclopramide E ctopic oestrogen T rauma skull/tumour breast, testes O rchitis C imetidine, Cushings L iver cirrhosis O besity P araplegia R A A cromegaly M ethyldopa I soniazid D igoxin E thionamide

Carbimazole is not associated with gynaecomastia. Please rate this question:


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Gynaecomastia

Gynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia Causes of gynaecomastia

physiological: normal in puberty

syndromes with androgen deficiency: Kallman's, Klinefelter's testicular failure: e.g. Mumps liver disease testicular cancer e.g. Seminoma secreting HCG ectopic tumour secretion

hyperthyroidism haemodialysis drugs: see below

Drug causes of gynaecomastia

spironolactone (most common drug cause) cimetidine digoxin

cannabis finasteride oestrogens, anabolic steroids

Very rare drug causes of gynaecomastia

tricyclics

isoniazid calcium channel blockers heroin busulfan methyldopa

Treatment options

identify and manage any overt underlying cause liposuction provides the best cosmetic outcome

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A 72 year old female is found to have a malignant lesion in her left arm. She had a mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left arm. What is the most likely cause of the malignancy?

Lymphangiosarcoma

Lymphoma

Myeloma

Angiomyolipoma

Giant cell tumour

Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy. Please rate this question:


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Lymphoedema

Due to impaired lymphatic drainage in the presence of normal capillary function. Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal

thickening. Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues);

muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis.

Causes of lymphoedema

Primary Congenital < 1 year: sporadic, Milroy's disease

Onset 1-35 years: sporadic, Meige's disease

> 35 years: Tarda

Secondary Bacterial/fungal/parasitic infection (filariasis)


Lymphatic malignancy

Radiotherapy to lymph nodes

Surgical resection of lymph nodes

DVT

Thrombophlebitis

Indications for surgery

Marked disability or deformity from limb swelling Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics

suitable for a lymphatic drainage procedure Lymphocutaneous fistulae and megalymphatics

Procedures

Homans operation Reduction procedure with preservation of overlying skin (which must be in

good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third.

Charles operation All skin and subcutaneous tissue around the calf are excised down to the

deep fascia. Split skin grafts are placed over the site. May be performed if

overlying skin is not in good condition. Larger reduction in size than with

Homans procedure.

Lymphovenous anastamosis

Identifiable lymphatics are anastomosed to sub dermal venules. Usually

indicated in 2% of patients with proximal lymphatic obstruction and normal

distal lymphatics.

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A 58 year old male is referred to endocrinology clinic for a parathyroidectomy by the F1 in medicine. His corrected calcium is 2.85 (2.2-2.6), PTH 7.5 (3-7) and 24h urinary calcium is 1.5 (2.5-7.5). What is the diagnosis?

Primary hyperparathyroidism

Secondary hyperparathyroidism

Tertiary hyperparathyroidism

Familial hypocalciuric hypercalcaemia

Hypercalacemia associated with malignancy

This F1 should have spoken to his senior. This patient has familial hypocalciuric hypercalcaemia, which requires no further action. A calcium to creatinine clearance ratio of <0.01 will confirm this diagnosis. Please rate this question:


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Parathyroid glands and disorders of calcium metabolism

Hyperparathyroidism

Disease type Hormone profile Clinical features Cause

Primary

hyperparathyroidism

PTH (Elevated)

Ca2+(Elevated)

Phosphate (Low)

Urine calcium :

creatinine clearance

ratio > 0.01

May be

asymptomatic if

mild

Recurrent

abdominal pain

(pancreatitis, renal

colic)

Changes to

emotional or

cognitive state

Most cases due to

solitary adenoma

(80%), multifocal

disease occurs in 10-

15% and parathyroid

carcinoma in 1% or

less



Secondary

hyperparathyroidism

PTH (Elevated)

Ca2+ (Low or

normal)

Phosphate

(Elevated)

Vitamin D levels

(Low)

May have few

symptoms

Eventually may

develop bone

disease, osteitis

fibrosa cystica and

soft tissue

calcifications

Parathyroid gland

hyperplasia occurs as

a result of low

calcium, almost

always in a setting of

chronic renal failure

Tertiary

hyperparathyroidism

Ca2+(Normal or

high)

PTH (Elevated)

Phosphate levels

(Decreased or

Normal)

Vitamin D (Normal

or decreased)

Alkaline

phosphatase

(Elevated)

Metastatic

calcification

Bone pain and /

or fracture

Nephrolithiasis

Pancreatitis

Occurs as a result of

ongoing hyperplasia

of the parathyroid

glands after

correction of

underlying renal

disorder, hyperplasia

of all 4 glands is

usually the cause

Differential diagnoses It is important to consider the rare but relatively benign condition of benign familial hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder. Diagnosis is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine clearance ratio <0.01-distinguished from primary hyperparathyroidism). Treatment Primary hyperparathyroidism Indications for surgery

Elevated serum Calcium > 1mg/dL above normal

Hypercalciuria > 400mg/day Creatinine clearance < 30% compared with normal Episode of life threatening hypercalcaemia Nephrolithiasis Age < 50 years

Neuromuscular symptoms Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more

than 2.5 standard deviations below peak bone mass (T score lower than -2.5)


Usually managed with medical therapy. Indications for surgery in secondary (renal) hyperparathyroidism:

Bone pain Persistent pruritus

Soft tissue calcifications

Tertiary hyperparathyroidism

Allow 12 months to elapse following transplant as many cases will resolve The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required. References 1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical Management.Surg Clin North Am 2009 Oct;89(5):1227-39. 2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J Endocrinol 2011; 2011: 251410.

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Theme: Management of breast cancer

A. Simple mastectomy alone

B. Radical mastectomy alone

C. Simple mastectomy and sentinel lymph node biopsy

D. Wide local excision and sentinel lymph node biopsy

E. Simple mastectomy and axillary node clearance

F. Radical mastectomy and axillary node clearance

G. Wide local excision and axillary node clearance

H. Wide local excision alone Please select the most appropriate treatment for the situation described. Each option may be used once, more than once or not at all.

15. A 44 year old lady presents with a mass in the upper outer quadrant of her right breast.

Imaging, histology and clinical examination confirm a 1.5cm malignant mass lesion with

no clinical evidence of axillary nodal disease.

You answered Simple mastectomy alone

The correct answer is Wide local excision and sentinel lymph node biopsy

A small peripheral lesion such as this would usually be suitable for breast conserving

surgery. Since imaging and clinical examination is not suspicious for axillary disease, a

sentinel lymph node biopsy should be performed.

16. A 44 year old lady presents with a mass lesion in the upper outer quadrant of the left

breast. On clinical examination she has a 2cm mass lesion which on core biopsy is

demonstrated to have invasive ductal carcinoma. An FNA of a bulky axillary lymph node

contains malignant cells.


The correct answer is Wide local excision and axillary node clearance

Although the primary lesion is small enough for breast conserving surgery, the presence of

overt axillary lymph node metastasis will attract a recommendation for axillary node

clearance.

17. A 39 year old lady presents with a mass lesion in her right breast. Clinical examination,

biopsy and imaging confirm a 2.5 cm lesion in the upper inner quadrant of her right breast

and a 1.5 cm lesion at the central aspect of the same breast. Her axilla shows

lymphadenopathy and a fine needle aspirate from the node shows malignant cells.


The correct answer is Simple mastectomy and axillary node clearance

A combination of established axillary disease and multifocal invasive lesions attracts an

indication for mastectomy and axillary clearance. A radical mastectomy is less frequently

indicated in modern surgical practice, disease that is locally advanced is often best

downstaged using medical therapy, rather than embarking on the operations for breast

cancer that were first popularised over 100 years ago.



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Breast cancer management

Surgery is performed in most patients suffering from breast cancer. Chemotherapy may be used to downstage tumours and allow breast conserving surgery.

Hormonal therapy may also be used for the same purposes.

Radiotherapy is given to all patients who have undergone breast conserving surgery. Patients who have undergone mastectomy may be offered a reconstructive procedure either

in conjunction with their primary resection or as a staged procedure at a later date.






DCIS >4cm DCIS <4cm



Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic

result may be obtained, this is rarely the case in small breasts Axillary disease

As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy.

Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance.

Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.

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A 50 year old lady is commenced on tamoxifen for the treatment of an oestrogen receptor positive breast cancer. Which of the following malignancies are associated with tamoxifen use?

Adenocarcinoma of the colon

Hodgkins lymphoma

Adenocarcinoma of the lung

Ovarian cancer

Endometrial cancer

Tamoxifen is an oestrogen receptor antagonist in breast tissues. However, at other sites, such as the endometrium it may act as an agonist. Hence the reason for increasing risk of endometrial cancer. Please rate this question:


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Tamoxifen

Synthetic partial oestrogen agonist, acts primarily by binding to the oestrogen receptor. Half life of 7 days, takes 4 weeks for drug to reach plasma steady state. Should usually be considered in patients with oestrogen receptor positive tumours

(alternative agents may be preferred in some groups). Although antagonistic with respects to breast tissue tamoxifen may serve as an agonist at

other sites. Therefore risk of endometrial cancer is increased, preservation of bone density and decreased cardiovascular risks.

Climateric side effects are common, 3% stop taking the drug because of these. Aromatase inhibitors are an alternative class of drugs, these work by blocking the peripheral

aromatization of androgens (post menopausal women produce oestrogens in this way). They may treat cancers for which tamoxifen is no longer effective.

Next question


Theme: Thyroid nodules

A. Toxic adenoma

B. Anaplastic carcinoma of thyroid

C. Follicular carcinoma of thyroid

D. Papillary carcinoma of thyroid

E. Medullary carcinoma of thyroid

F. Thyroid lymphoma

G. Multinodular goitre

H. Parathyroid gland tumour For each scenario please select the most likely underlying diagnosis. Each option may be used once, more than once or not at all.

19. A 52 year old woman with known Hashimotos thyroiditis presents with a neck swelling.

She describes it as rapidly increasing in size over 3 months and she complains of

dysphagia to solids. On examination there is an asymmetrical swelling of the thyroid

gland.

You answered Toxic adenoma

The correct answer is Thyroid lymphoma

Thyroid lymphoma (Non Hodgkin's B cell lymphoma) is rare. It should be considered in

patients with a background of Hashimoto's thyroiditis and a rapid growth in size of the

thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional

biopsy may be needed. Radiotherapy is the main treatment option.

20. A 52 year old woman presents with a neck swelling. On examination she is noted to have

single nodule on the thyroid gland. A CXR shows two mass lesions.

You answered Toxic adenoma

The correct answer is Follicular carcinoma of thyroid

A solitary nodule with signs of haematogenous spread indicates a follicular tumour. Note

that papillary tumours tend to be multinodular and spread via the lymphatic

system.Lymphatic spread from a papillary thyroid cancer is nearly always to neck nodes in

the first instance and mediastinal lymphadenopathy is vanishingly rare. Lung lesions are

typically synonymous with haematogenous metastasis of which a follicular lesion is the

most likely culprit.

21. A 52 year old woman presents with a neck swelling. Her GP reports that her TSH value is

low at 0.01. A scintigraphy demonstrates a hot nodule.

Toxic adenoma

This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic

adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.



Next question

Thyroid disease

Patients may present with a number of different manifestations of thyroid disease. They can be broadly sub classified according to whether they are euthyroid or have clinical signs of thyroid dysfunction. In addition it needs to be established whether they have a mass or not. Assessment

History Examination including USS

If a nodule is identified then it should be sampled ideally via an image guided fine needle aspiration

Radionucleotide scanning is of limited use

Thyroid Tumours

Papillary carcinoma

Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Lymphoma's

Multinodular goitre

One of the most common reasons for presentation

Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured.

In those with compressive symptoms surgery is required and the best operation is a total thyroidectomy.

Sub total resections were practised in the past and simply result in recurrent disease that requires a difficult revisional resection.


Endocrine dysfunction

In general these patients are managed by physicians initially. Surgery may be offered alongside radio iodine for patients with Graves disease that fails with

medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).

Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine.

Complications following surgery

Anatomical such as recurrent laryngeal nerve damage. Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory

compromise owing to laryngeal oedema.

Damage to the parathyroid glands resulting in hypocalcaemia.

Further sources of information

1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical Biochemistry guidelines for thyroid function tests. 2. British association of endocrine surgeons website- http://www.baets.org.uk

Next question

Which investigation is best for initial assessment of recurrence of follicular carcinoma of the thyroid?

Free T4

Thyroid stimulating hormone

Scintigraphy

Serum thyroglobulin

USS thyroid gland

Elevated thyroglobulin levels raises suspicion of recurrence. Please rate this question:


Next question

Thyroid malignancy

Papillary carcinoma

Commonest sub-type

Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so

called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic

thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma

Follicular carcinoma

Are less common than papillary lesions

Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation

Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate

Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy


Anaplastic carcinoma

Less common and tend to occur in elderly females Disease is usually advanced at presentation and often only palliative decompression and

radiotherapy can be offered.

Medullary carcinoma

These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin.

The serum calcitonin may be elevated which is of use when monitoring for recurrence. They may be familial and occur as part of the MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived

primarily from thyroid cells they are not responsive to radioiodine.

Lymphoma

These respond well to radiotherapy Radical surgery is unnecessary once the disease has been diagnosed on biopsy material.

Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Next question

A 33 year old lady attends the clinic with a 3 month history of palpitations and irritability. Her thyroid function, PTH and calcium are measured: Thyroid function

Free T4 40 pmol/L

TSH < 0.1 miu/L

Free T3 25 p mol/L (normal 3.5-7.7 p mol/L)

PTH 10pg/ml (normal 10-55pg/ml)

(Normal values listed in reference range link) What is the most likely diagnosis?

Hypothyroidism

Hyperthyroidism

Hypoparathyroidism

Hyperparathyroidism

Euthyroid

Theme from April 2012 Exam Elevated T4 and suppressed TSH makes this the most likely diagnosis. The PTH level is normal. Please rate this question:


Next question

Hyperthyroidism

Causes of hyperthyroidism include:

Diffuse toxic goitre (Graves Disease) Toxic nodular goitre Toxic nodule Rare causes


Graves disease

Graves disease is characterised by a diffuse vascular goitre that appears at the same time as the clinical manifestations of hyperthyroidism. It is commonest in younger females and may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of patients will have a familial history of autoimmune disorders. The glandular hypertrophy and hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor antibodies. Toxic nodular goitre

In this disorder the goitre is present for a long period of time prior to the development of clinical symptoms. In most goitres the nodules are inactive and in some cases it is the internodular tissue that is responsible for the hyperthyroidism. Toxic nodule Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning thyroid tissue will exert a negative feedback effect. Signs and symptoms

Symptoms Signs

Lethargy Tachycardia

Emotionally labile Agitation

Heat intolerance Hot, moist palms

Weight loss Exopthalmos

Excessive appetite Thyroid goitre and bruit

Palpitations Lid lag/retraction

Diagnosis The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of Graves. Treatment First line treatment for Graves disease is usually medical and the block and replace regime is the favored option. Carbimazole is administered at higher doses and thyroxine is administered orally. Patient are maintained on this regime for between 6 and 12 months. Attempts are then made to

wean off medication. Where relapse then occurs the options are between ongoing medical therapy, radioiodine or surgery.

Next question

A 23 year old lady has Graves disease that has relapsed on stopping anti thyroid drugs, radioiodine is offered as the next treatment by the endocrinologists. Which statement is false?

Close contact with children is not permitted for up to 4 weeks following treatment

15% of patients with opthalmopathy will see worsening of eye signs

Symptomatic improvement takes 6-8 weeks

Up to 80% of patients will become hypothyroid

It increases the risk of parathyroid carcinoma

Radio-iodine- may worsen opthalmopathy, contraindicated in pregnancy and those wishing to concieve within 6 months.

Radioiodine vs. Surgery

Surgery Radioiodine

Symptomatic improvement within 10 days Symptomatic improvement takes up to 2 months

No effect on opthalmopathy Eye signs may worsen

Risk of damage to adjacent anatomical

structures

No risk of anatomical damage

No restrictions on contact No contact with children for 4 weeks



Next question

Thyroid disease



History Examination including USS

If a nodule is identified then it should be sampled ideally via an image guided fine needle aspiration


Thyroid Tumours

Papillary carcinoma


Multinodular goitre

One of the most common reasons for presentation

Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured.




In general these patients are managed by physicians initially.

Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).








Next question

Theme: Thyroid disease

A. Papillary carcinoma

B. Follicular carcinoma

C. Multinodular goitre

D. Parathyroid adenoma

E. Anaplastic thyroid carcinoma

F. Medullary carcinoma

G. Toxic nodule

H. Graves disease Please select the most likely thyroid lesion for the scenario given. Each option may be used once, more than once or not at all.

25. A 34 year old female presents with a thyroid nodule. She has a family history of thyroid

disease and both her sisters have undergone total thyroidectomies. Her past medical

history includes hypertension which has been difficult to manage.

You answered Papillary carcinoma

The correct answer is Medullary carcinoma

This is a typical scenario for medullary carcinoma in which a phaeochromocytoma may

also be present. It may be inherited in an autosomal dominant fashion and affected family

members may be offered prophylactic thyroidectomy.

26. A 46 year old man is admitted to hospital with a femoral shaft fracture that occurred

suddenly whilst he was out walking his dog. On examination there is no neurovascular

deficit distal to the fracture site. He has a large firm nodule in the left lobe of the thyroid,

there is no associated lymphadenopathy.

You answered Papillary carcinoma

The correct answer is Follicular carcinoma

Follicular carcinomas may metastasise haematogenously (often to bone) where they may

give rise to pathological fractures as in this case.

27. An 18 year old female presents with 3 nodules in the right lobe of the thyroid. Clinically

she is euthyroid and there is associated cervical lymphadenopathy. She has no family

history of thyroid disease.

Papillary carcinoma

Papillary thyroid cancers are the most common type of thyroid cancer and are the more

common in females (M:F=1:3). Papillary tumours are more likely to develop lymphatic

spread than follicular tumours.



Next question

Thyroid disease


History

Examination including USS If a nodule is identified then it should be sampled ideally via an image guided fine needle

aspiration


Thyroid Tumours

Papillary carcinoma Follicular carcinoma

Anaplastic carcinoma Medullary carcinoma Lymphoma's

Multinodular goitre

One of the most common reasons for presentation Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they

can be reassured.





In general these patients are managed by physicians initially. Surgery may be offered alongside radio iodine for patients with Graves disease that fails with

medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).








Next question

A 19 year old male presents with bilateral gynaecomastia, poor vision and nipple discharge. Which of the following blood tests is most likely to be abnormal?

Oestrogen

Testosterone

β HCG

Prolactin

Calcitonin

A combination of nipple discharge, gynaecomastia and poor vision may well be associated with a prolactinoma. The poor vision results from compression of the optic chiasm resulting in bi temporal hemianopia. Please rate this question:


Next question

Gynaecomastia

Gynaecomastia describes an abnormal amount of breast tissue in males and is usually caused by an increased oestrogen:androgen ratio. It is important to differentiate the causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of gynaecomastia Causes of gynaecomastia

physiological: normal in puberty syndromes with androgen deficiency: Kallman's, Klinefelter's testicular failure: e.g. Mumps

liver disease testicular cancer e.g. Seminoma secreting HCG ectopic tumour secretion hyperthyroidism haemodialysis drugs: see below


Drug causes of gynaecomastia

spironolactone (most common drug cause)

cimetidine digoxin cannabis finasteride oestrogens, anabolic steroids

Very rare drug causes of gynaecomastia

tricyclics isoniazid calcium channel blockers

heroin busulfan methyldopa

Treatment options

identify and manage any overt underlying cause

liposuction provides the best cosmetic outcome

Next question

Theme: Management of calcium metabolic disorders

A. No action needed

B. Intravenous fluid (0.9% N.Saline)

C. Risedronate and calcium supplements

D. Calcium supplements

E. Exploration and parathyroidectomy

F. DEXA bone scan

G. Pamidronate IV For each scenario please select the most appropriate management plan. Each option may be used once, more than once or not at all.

29. An 80 year old woman has a hip fracture. Her calcium is normal. She has never been given

a diagnosis of osteoporosis.

You answered No action needed

The correct answer is Risedronate and calcium supplements

The osteoporosis guidelines state if a postmenopausal woman has a fracture she should be

put on bisphosphonates (there is no need for a DEXA scan).

30. A 60 year old man presents with recurrent renal stones. He is found to have a calcium of

2.72 (elevated) and a PTH of 12 (elevated).


The correct answer is Exploration and parathyroidectomy

This patient has primary hyperparathyroidism and nephrolithiasis, which is an indication

for parathyroidectomy.

31. An 82 year old woman from a nursing home is admitted to the orthopaedic ward with a hip

fracture. She is acutely confused and agitated. Her Calcium is 2.95 (elevated).


The correct answer is Intravenous fluid (0.9% N.Saline)

This patient needs rehydration due to hypercalcaemia. An intravenous bisphosphonate is

indicated if the Ca is above 3.



Next question


Hyperparathyroidism


Primary

hyperparathyroidism

PTH (Elevated)

Ca2+(Elevated)

Phosphate (Low)

Urine calcium :


ratio > 0.01

May be

asymptomatic if

mild

Recurrent

abdominal pain


colic)

Changes to

emotional or

cognitive state

Most cases due to

solitary adenoma

(80%), multifocal


15% and parathyroid

carcinoma in 1% or

less

Secondary

hyperparathyroidism

PTH (Elevated)

Ca2+ (Low or

normal)

Phosphate

(Elevated)

Vitamin D levels

(Low)

May have few

symptoms

Eventually may

develop bone

disease, osteitis

fibrosa cystica and

soft tissue

calcifications

Parathyroid gland


a result of low

calcium, almost



Tertiary

hyperparathyroidism

Ca2+(Normal or

high)

PTH (Elevated)

Phosphate levels

(Decreased or

Normal)

Vitamin D (Normal

or decreased)

Alkaline

phosphatase

(Elevated)

Metastatic

calcification

Bone pain and /

or fracture

Nephrolithiasis

Pancreatitis


ongoing hyperplasia

of the parathyroid

glands after

correction of

underlying renal


of all 4 glands is

usually the cause

Differential diagnoses


It is important to consider the rare but relatively benign condition of benign familial hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder. Diagnosis is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine clearance ratio <0.01-distinguished from primary hyperparathyroidism). Treatment Primary hyperparathyroidism Indications for surgery


Hypercalciuria > 400mg/day Creatinine clearance < 30% compared with normal Episode of life threatening hypercalcaemia Nephrolithiasis Age < 50 years Neuromuscular symptoms

Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)

Secondary hyperparathyroidism Usually managed with medical therapy. Indications for surgery in secondary (renal) hyperparathyroidism:

Bone pain

Persistent pruritus Soft tissue calcifications

Tertiary hyperparathyroidism Allow 12 months to elapse following transplant as many cases will resolve The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required. References 1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical Management.Surg Clin North Am 2009 Oct;89(5):1227-39. 2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J Endocrinol 2011; 2011: 251410.

Next question

Theme: Management of thyroid disease

A. Total Thyroidectomy

B. Thyroid lobectomy

C. Sub total thyroidectomy

D. Radioactive iodine

E. Carbimazole

F. Tru cut biopsy

G. Further fine needle aspiration

H. Observation For each scenario please select the most appropriate management option. Each option may be used once, more than once or not at all.

32. A 59 year old man is referred with symptoms of dysphagia. On examination he has a large

goitre and on imaging there is significant retrosternal extension and features of a

multinodular goitre.

Total Thyroidectomy

Sub total thyroidectomy is no longer routinely undertaken in this group.

33. A 48 year old lady with thyrotoxicosis is referred to the clinic, she was poorly controlled

on carbimazole and has received orbital radiotherapy for severe proptosis. This has

improved matters but she relapsed on stopping her carbimazole.

Total Thyroidectomy

Eye signs worsen with radioiodine.

34. A 23 year old lady has re attended the clinic on three occasions with a cyst in her thyroid

that refills. Cytology on each occasion is reassuring.

You answered Total Thyroidectomy

The correct answer is Thyroid lobectomy

Persist refilling cysts may be associated with a well differentiated tumour and should be

removed by lobectomy.



Next question

Thyroid disease


History Examination including USS If a nodule is identified then it should be sampled ideally via an image guided fine needle

aspiration Radionucleotide scanning is of limited use

Thyroid Tumours

Papillary carcinoma


Multinodular goitre

One of the most common reasons for presentation Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they

can be reassured. In those with compressive symptoms surgery is required and the best operation is a total

thyroidectomy. Sub total resections were practised in the past and simply result in recurrent disease that

requires a difficult revisional resection.


In general these patients are managed by physicians initially.

Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women).

Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis,


however, with time the toxic phase passes and patients can simply be managed with thyroxine.



compromise owing to laryngeal oedema. Damage to the parathyroid glands resulting in hypocalcaemia.

Further sources of information 1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical Biochemistry guidelines for thyroid function tests. 2. British association of endocrine surgeons website- http://www.baets.org.uk

Next question

Which of the following are not true of follicular thyroid cancer?

They often appear to be encapsulated.

Those with a Hurthle cell subtype have an excellent prognosis.

Haematogenous metastasis is more common than in Papillary carcinoma.

The overall mortality rate is 24%.

Vascular invasion is seen in up to 60% of cases.

The Hurthle cell subtype have a worse prognosis. Please rate this question:


Next question

Thyroid malignancy

Papillary carcinoma

Commonest sub-type

Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so

called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic

thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma


Are less common than papillary lesions

Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation

Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate

Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy





Medullary carcinoma




Lymphoma



Next question

Theme: Thyroid function tests

A. Thyrotoxicosis

B. Sick euthyroid syndrome

C. Hypothyroidism

D. Poor compliance with thyroid medication

E. Hashimotos thyroiditis

F. Multinodular goitre

Please select the most likely diagnosis for the scenario given. Each option may be used once, more

than once or not at all.

36. A 52 year old woman presents with an acute ischaemic right arm. She is found to have fast atrial

fibrillation. Her blood results reveal a free T4 level of 20 and a TSH of < 0.01.

Thyrotoxicosis

Theme from January 2013

The diagnosis is thyrotoxicosis. An elevated T4 and a low TSH should indicate this diagnosis.

Remember atrial fibrillation and its complications i.e acute ischaemic limbs can be precipitated by

hyperthyroid disorders.

37. A 42 year old woman presents with a goitre. On examination the goitre feels 'lumpy'. The blood

results reveal a TSH of 12 and a free T4 of 2. Antithyroid peroxidase antibodies are high.

You answered Thyrotoxicosis

The correct answer is Hashimotos thyroiditis

Hashimotos usually presents in women aged between 30- 50 years. They are normally associated

with a goitre. To differentiate from hypothyroidism, the antithyroid peroxidase antibodies will be

elevated.

38. A 55 year old man is on the intensive care unit for many months after open aortic surgery. He is

maintained on total parenteral nutrition. Clinically he is euthyroid, but his thyroid function tests

reveal a low TSH and low T4.

You answered Thyrotoxicosis

The correct answer is Sick euthyroid syndrome

Sick euthyroid syndrome is most commonly seen in chronically ill patients or those with

starvation. The thyroid function tests are often low and the patient clinically euthyroid.



Next question

Thyroid function tests

The interpretation of thyroid function tests is usually straightforward:

Disorder TSH Free T4

Thyrotoxicosis (e.g. Graves' disease) Low High In T3 thyrotoxicosis the free T4 will be

normal

Primary hypothyroidism (primary

atrophic hypothyroidism)

High Low

Secondary hypothyroidism Low Low Replacement steroid therapy is

required prior to thyroxine


Disorder TSH Free T4

Sick euthyroid syndrome* Low** Low Common in hospital inpatients

Poor compliance with thyroxine High Normal /

high

Steroid therapy Low Normal

*now referred to as non-thyroidal illness

**TSH may be normal in some cases

Next question

Theme: Nottingham prognostic index

A. <2.5

B. <3.4

C. 3.4-5.4

D. >5.4

Please match the prognosis of patients who have undergone breast cancer surgery to the most

appropriate Nottingham Prognostic Index score. Each option may be used once, more than once or

not at all.

39. Worst prognostic group

You answered <2.5

The correct answer is >5.4

The Nottingham prognostic index may be used to stratify patients into various prognostic groups

(see below). An excellent prognosis is seen with a score of <2.4. Scores of over 5 equate to a

greatly reduced survival rate.

40. Intermediate prognosis

You answered <2.5

The correct answer is 3.4-5.4

41. Excellent prognosis

<2.5



Next question

Nottingham prognostic index

The Nottingham Prognostic Index can be used to give an indication of survival following breast

cancer surgery. In this system, the tumour size is weighted less heavily than other major prognostic

parameters.

Calculation of NPI

Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).

Score

Lymph nodes involved Grade

1 0 1

2 1-3 2

3 >3 3

Prognosis


2.0 to 2.4 93%

2.5 to 3.4 85%


3.5 to 5.4 70%

>5.4 50%

This data was originally published in 1992. It should be emphasised that other factors such as

vascular invasion and receptor status also impact on survival and are not included in this data and

account for varying prognoses often cited in the literature.

Reference

Galea, M.H., et al., The Nottingham Prognostic Index in primary breast cancer. Breast Cancer Res

Treat, 1992. 22(3): p. 207-19.

Next question

A 56 year old lady undergoes a mastectomy as treatment for multifocal ductal carcinoma in situ. Two weeks post operatively she attends the clinic and complains of a diffuse swelling at the surgical site. On examination she has a large, fluctuant area underlying the mastectomy skin flaps. She is otherwise well. What is the most likely cause?

Abscess

Seroma

Haematoma

Disease recurrence

Arteriovenous malformation

Seromas are very common after breast surgery. The exposed raw surfaces created during the elevation of the skin flaps are a common cause. Treatment usually involves percutaneous drainage under aseptic conditions. Please rate this question:


Next question

Complications of breast surgery

Breast surgery may be associated with the following complications:

Long thoracic nerve injury. This may occur during the axillary dissection and result in winging of the scapula.

Intercostobrachial nerve injury. These nerves traverse the axilla. When they are divided (which they often are) the patient will notice an area of parasthesia in the armpit.

Injury to the thoracodorsal trunk. This nerve and vessels supply latissimus dorsi. If they are damaged the functional effects are not too serious, the greatest setback is that a latissimus dorsi flap cannot be used for reconstruction purposes.

Infections. Cellulitis of the chest wall and arm may be a major problem if axillary nodal clearance is undertaken. Infections may run a protracted course and require polytherapy for treatment.

Lymphoedema. Usually complicates axillary node clearance or irradiation. Treatment is with manual lymphatic drainage and compression sleeves.

Seroma. This is an accumulation of fluid at the site of surgery. The fluid is usually straw coloured and may re-accumulate despite drainage. Most will resolve with time.


You are the specialist trainee in endocrinology clinic. The medical team have referred a man for a parathyroidectomy who has a corrected calcium of 2.82 (elevated) and a PTH of 11 (elevated). Which of the following is not an indication for parathyroidectomy?

Nephrolithiasis

Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of

more than 2.5 standard deviations below peak bone mass

Age < 50 years

Episode of life threatening hypercalcaemia

None of the above

All of the situations listed are indications for parathyroidectomy. See below for more information. Please rate this question:


Next question


Hyperparathyroidism


Primary hyperparathyroidism

PTH (Elevated)

Ca2+(Elevated)

Phosphate (Low)

Urine calcium :


ratio > 0.01

May be

asymptomatic if

mild

Recurrent

abdominal pain


colic)

Changes to

emotional or

cognitive state

Most cases due to

solitary adenoma

(80%), multifocal


15% and parathyroid

carcinoma in 1% or

less

Secondary PTH (Elevated) May have few Parathyroid gland



hyperparathyroidism Ca2+ (Low or

normal)

Phosphate

(Elevated)

Vitamin D levels

(Low)

symptoms

Eventually may

develop bone

disease, osteitis

fibrosa cystica and

soft tissue

calcifications


a result of low

calcium, almost



Tertiary

hyperparathyroidism

Ca2+(Normal or

high)

PTH (Elevated)

Phosphate levels

(Decreased or

Normal)

Vitamin D (Normal

or decreased)

Alkaline

phosphatase

(Elevated)

Metastatic

calcification

Bone pain and /

or fracture

Nephrolithiasis

Pancreatitis


ongoing hyperplasia

of the parathyroid

glands after

correction of

underlying renal


of all 4 glands is

usually the cause

Differential diagnoses It is important to consider the rare but relatively benign condition of benign familial hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder. Diagnosis is usually made by genetic testing and concordant biochemistry (urine calcium : creatinine clearance ratio <0.01-distinguished from primary hyperparathyroidism). Treatment Primary hyperparathyroidism Indications for surgery


Hypercalciuria > 400mg/day Creatinine clearance < 30% compared with normal Episode of life threatening hypercalcaemia Nephrolithiasis Age < 50 years Neuromuscular symptoms

Reduction in bone mineral density of the femoral neck, lumbar spine, or distal radius of more than 2.5 standard deviations below peak bone mass (T score lower than -2.5)


Usually managed with medical therapy. Indications for surgery in secondary (renal) hyperparathyroidism:

Bone pain

Persistent pruritus Soft tissue calcifications

Tertiary hyperparathyroidism Allow 12 months to elapse following transplant as many cases will resolve The presence of an autonomously functioning parathyroid gland may require surgery. If the culprit gland can be identified then it should be excised. Otherwise total parathyroidectomy and re-implantation of part of the gland may be required. References 1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical Management.Surg Clin North Am 2009 Oct;89(5):1227-39. 2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J Endocrinol 2011; 2011: 251410.

Next question

Theme: Breast disease treatment

A. Mastectomy

B. Sentinel lymph node biopsy

C. Axillary node clearance

D. Wide local excision

E. Breast lump excision biopsy

F. Image guided wide local excision

G. Radiotherapy

H. Chemotherapy

I. Excision of margins

J. Discharge to routine follow-up Please select the most appropriate management option from the list for the scenario given. Each option may be used once, more than once or not at all.

44. A 35 year old woman has undergone a wide local excision. The histology shows an

invasive lobular carcinoma present at 3 of the resection margins. Cavity shavings taken at

the original operation are also involved. Sentinel node biopsy was negative.

Mastectomy

This patient has an extensive disease process and lobular cancers are notorious for being

multifocal. In this case a mastectomy is the safest next step.

45. A 56 year old woman has undergone a wide local excision and axillary node sample. The

histology shows a 2.5cm invasive ductal carcinoma grade 1 which is completely excised.

None of the axillary lymph nodes show evidence of metastatic disease.

You answered Mastectomy

The correct answer is Radiotherapy

This woman has a good prognosis. However, irradiation of the breast is mandatory after

breast cancer has been treated using breast conserving surgery.

46. A 28 year old female presents with a painless lump in the upper outer quadrant of her left

breast. Imaging using ultrasound is indeterminate (U3). Two core biopsies have now been

performed and both show normal breast tissue (B1).

You answered Mastectomy

The correct answer is Breast lump excision biopsy

The imaging and biopsy results are not concordant. At this stage an excision biopsy is the

safest option.



Next question

Breast cancer management

Surgery is performed in most patients suffering from breast cancer. Chemotherapy may be used to downstage tumours and allow breast conserving surgery.

Hormonal therapy may also be used for the same purposes.

Radiotherapy is given to all patients who have undergone breast conserving surgery. Patients who have undergone mastectomy may be offered a reconstructive procedure either

in conjunction with their primary resection or as a staged procedure at a later date.






DCIS >4cm DCIS <4cm


Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic

result may be obtained, this is rarely the case in small breasts Axillary disease


As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy.

Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance.

Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.

Next question

Theme: Non operative treatment of breast cancer

A. Radiotherapy

B. Cytotoxic chemotherapy

C. Surveillence alone

D. Endocrine therapy using tamoxifen

E. Endocrine therapy using letrozole

F. Endocrine therapy using medroxyprogesterone acetate Please select the most appropriate agent for the situation described. Each option may be used once, more than once or not at all.

47. A 55 year old lady has undergone a wide local excision and sentinel lymph node biopsy

for breast cancer. The histology report shows a completely excised 1.3cm grade 1 invasive

ductal carcinoma. The sentinel node contained no evidence of metastatic disease. The

tumour is oestrogen receptor negative.

Radiotherapy

Radiotherapy is routine following breast conserving surgery. Without irradiation the local

recurrence rates are approximately 40%.

48. An 88 year old lady presents with a large mass in the upper inner quadrant of her right

breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma.

She has declined operative treatment.

You answered Radiotherapy

The correct answer is Endocrine therapy using letrozole

Elderly patients may be managed using endocrine therapy alone. Eventually most will

escape hormonal control. In post menopausal women oestrogens are produced by the

peripheral aromatization of androgens and aromatase inhibitors are therefore the most

popular agent in this age group.

49. A 38 year old lady has undergone a mastectomy and axillary node clearance for invasive

ductal carcinoma. The histology report shows a completely excised 3.5cm lesion which is

grade 3. Two of the axillary lymph nodes contain metastatic disease. The tumour is

oestrogen receptor negative.

You answered Radiotherapy

The correct answer is Cytotoxic chemotherapy

The combination of a grade 3 tumour and axillary nodal metastasis in a young female

would attract a recommendation for chemotherapy. Some may also add herceptin (if they

are HER 2 positive).



Next question

Breast cancer treatment

Treatment Indication

Endocrine therapy

Oestrogen receptor positive tumours

Downstaging primary lesions

Definitive treatment in old, infirm patients

Irradiation Wide local excision

Large lesion, high grade or marked vascular invasion following

mastectomy

Chemotherapy Downstaging advanced lesions to facilitate breast conserving surgery

Patients with grade 3 lesions or axillary nodal disease

Endocrine agents

Tamoxifen is used and works as a partial oestrogen receptor agonist. It will typically block activity at the breast. It does, however, stimulate the receptors at other sites and it is this that accounts for its association with endometrial cancer. In post menopausal women the process of aromatisation accounts for most oestrogen production. Therefore in this group aromatase inhibitors are the preferred agents. Women who are perimenopausal start on tamoxifen and switch at 3 years. Chemotherapy

The FEC regime is most commonly used (Fluorouracil, epirubicin and cyclophosphamide). This was found to be superior to the older CMF regime. The Taxanes are commonly used in high risk patients and in this setting a regime of docetaxal, doxorubicin and cyclophosphamide may be used. The anthracycline class drugs have marked cardiotoxicity (a property that they share with trastuzumab) and this can limit their use.

Next question


Which of the following statements regarding papillary carcinoma of the thyroid is false?

They account for the majority of thyroid carcinomas

Spread predominantly via the lymphatics

May be diagnosed using fine needle aspiration cytology

When viewed microscopically may demonstrate 'orphan Annie 'nuclei

Have a five year survival of 65% if confined to the thyroid alone

The prognosis for localised papillary carcinomas is excellent. Survival rates at 5 years approach 90%. Please rate this question:


Next question

Thyroid malignancy

Papillary carcinoma

Commonest sub-type Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so

called 'orphan Annie' nuclei

They typically metastasise via the lymphatics and thus laterally located apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma


Are less common than papillary lesions Like papillary tumours, they may present as a discrete nodule. Although they appear to be

well encapsulated macroscopically there is invasion on microscopic evaluation Lymph node metastases are uncommon and these tumours tend to spread

haematogenously. This translates into a higher mortality rate Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus

all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy





Medullary carcinoma




Lymphoma



Next question

Theme: Breast malignancy

A. Eczema of the nipple

B. Ductal carcinoma in situ

C. Mucinous carcinoma

D. Invasive ductal carcinoma

E. Invasive lobular carcinoma

F. Paget's disease of the nipple

G. Lobular carcinoma in situ. What is the likely diagnosis for the scenario given? Each option may be used once, more than once, or not at all.

51. A 74 year old woman presents with a breast lump. On examination is has a soft

consistency. The lump is removed and sliced apart. Macroscopically there is a grey,

gelatinous surface.

You answered Eczema of the nipple

The correct answer is Mucinous carcinoma

Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the special

type of carcinomas. These have a better prognosis that tumours of Non Special Type

(NST) and axillary nodal disease is rare in this group.

52. A 74 year old woman presents with an erythematous rash originating in the nipple. It is

spreading to the surrounding areolar area and the associated normal tissue.


The correct answer is Paget's disease of the nipple

Paget's is associated with DCIS or invasive carcinoma.Unlike eczema of the nipple which

predominantly affects the areolar region, Pagets will usually affect the nipple first and then

spread to the areolar area. Diagnosis is made by punch biopsy.

53. A 53 year old woman presents with a bloody nipple discharge. On mammography there is

calcification behind the nipple areolar complex. A core biopsy shows background benign

change, but cells that show comedo necrosis which have not breached the basement

membrane.


The correct answer is Ductal carcinoma in situ

Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high

risk of being associated with foci of invasion.



Breast cancer














DCIS >4cm DCIS <4cm



result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast

conserving surgery


Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years [1]. Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below).





1 0 1

2 1-3 2

3 >3 3

Prognosis


2.0 to 2.4 93%

2.5 to 3.4 85%

3.5 to 5.4 70%

>5.4 50%

This data was originally published in 1992. It should be emphasised that other factors such as vascular invasion and receptor status also impact on survival and are not included in this data and account for varying prognoses often cited in the literature. References Surgical guidelines for the management of breast cancer, Association of Breast Surgery at BASO 2009, Eur J Surg Oncol (2009), doi:10.1016/j.ejso.2009.01.008

Mastectomy and axillary node clearance Wide local excision ...

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