ABSITE REVIEW WEBINAR High Yield Review- Breast and Endocrine Topics

DEPARTMENT OF SURGERY

Amanda Sosulski, MD PGY-5 General Surgery BREAST PEARLS OVERVIEW

• General • Know anatomy and physiology • Risk Lesions/Risk Factors • Arterial and venous supply • LCIS • Lymphatic drainage • Atypia • Including levels of axillary • Genetic dissection • environmental • Nerve innervation and • Malignancy possible injury • Carcinoma In Situ • Complications of breast procedures • Pagets disease • Types of breast surgery • Invasive Ductal • Lumpectomy • Invasive lobular • mastectomy • Inflammatory breast cancer • Benign • Special situations • Fibroadenoma • Pregnancy • Fat necrosis • Gynecomastia • Phylloides Tumor • Cysts • Male breast cancer • Nipple discharge • Cancer syndromes Breast Surgery Pearls

HIGH YIELD ANATOMY

• Long thoracic nerve serratus anterior • injury winged scapula • Thoracodorsal nerve  lattisimus dorsi • injury weak arm pull ups/adduction • Medial pectoral nerve  pec major/minor • Lateral pectoral nerve  pec major – • risk of injury when level 3 nodes take • Intercostobrachial nerve  just below axillary vein- • MC injured with axillary dissection  numbness to medial arm and axilla • Batsons plexus  valveless venous plexus allows hematogenous mets to spine • Lymph drainage 97% to axillary nodes, 2% to internal mammary nodes • Supraclavicular disease N3c BREAST- BENIGN • Infectious • Breast abscess- should be associated with breast feeding otherwise, association with smoking, and if not resolved in 2 weeks r/o necrotic breast cancer • Periductal mastitis-noncyclical pain, erythema, tender mass behind nipple • Cyclical/Cystic • Simple cyst- palpable, simple cyst aspirate if clear does not recur- ok, if bloody or recurs send cytology need excisional biopsy • Fibrocystic changes- many subtypes, pain and tissue changes with cycle– benign unless biopy with Atypical Hyperplasia • Mastodynia – pain in breast cyclical, association with fibrocystic disease • Galactocele – cyst filled with milk – breast feeding • Benign neoplasms • Fibroadenoma – MC adolescent/young women, slow growing, firm well circumscribed, U/S confirmation and core needle biopsy shows fibroadenoma, may watch, otherwise excisional biopsy • Phyllodes tumor- 85% benign, hematogenous spread, stromal tumor resembling giant fibroadenoma, fast growing  WLE with 1cm margins BENIGN CONTINUED

• Nipple drainage • Yellow-green-brown –Fibrocystic, need exam compatible • Bloody- Intraductal papilloma- MCC • Benign, get ductogram and excise to rule out ductal ca • Serous or spontaneous drainage- worry about cancer- ductogram and excision • Risk Lesions/Factors • LCIS-30% lifetime risk of breast CA either breast • BRCA I/II • Atypia • FHx BREAST MALIGNANT • Carcinoma In Situ (DCIS- lumpectomy/+/-XRT vs simple mastectomy +SLNBx) • DCIS- no invasion of basement membrane, cluster of calcifications on mammo • Solid, cribriform, papillary, comedo forms (worst prognosis) • Invasive Carcinoma – MRM or BCT + XRT • Ductal- 85%- many subtypes • Lobular- 10% infiltrative, BL multicentric • Inflammatory Breast Cancer • T4 disease, very aggressive, poor prognosis, peau d’orange • Full thickness biopsy with skin • Neoadjuvant chemo/MRM/adjuvant chemo • Paget’s Disease of Nipple • Dermatitis/scaling of nipple- suspect underlying DCIS or invasive cancer • Full thickness nipple biopsy • MRM- exicison Nipple areolar complex MALIGNANT CONTINUED

• Surgical Treatment • Modified radical Mastectomy(axilla levels I/II) vs BCT/SLNBx + radiation • Staging and Prognosis • TNM stages • LN status most important prognostic indicator • Indications for chemo/endocrine • <1cm negative nodes- no chemo, hormonal therapy • >1cm negative nodes- chemo if ER/PR-, otherwise hormonal • Node + chemo, except elderly females – only aromatase inhibitor BREAST OTHER • Pregnancy – U/S and CNBx • Higher node positivity, more advanced stage • 1st early 2nd trimester MRM, chemo during 2nd trimester • Late 2nd/early 3rd  MRM/chemo, BCT+SLNB + chemo/XRT, SLNB + chemo followed by BCT/radiation • Male Breast cancer • BRCA II • Usually hormone + • MRM to treat • Gynecomastia • Usuallly benign, adolescents • Adults due to increased estrogen states, medications • Mondors Disease • Superficial thrombophlebitis of breast • Stewart Treves Syndrome • Lymphangiosarcoma from chronic lymphedema, dark purple nodules A 32y patient in her second trimester is diagnosed with an invasive 2m ductal carcinoma of her R breast, ER/PR positive. All but the following are true: • A- surgery can be performed in any trimester • B- MRM or breast conserving therapy may be performed • C- Therapy with tamoxifen should start during pregnancy • D- Chemotherapy with doxorubicin or cyclophosphamide can be performed after the first trimester • E- Sentinel node biopsy can be performed with radioactive tracer without ill effects A 32y patient in her second trimester is diagnosed with an invasive 2m ductal carcinoma of her R breast, ER/PR positive. All but the following are true: • A- surgery can be performed in any trimester • B- MRM or breast conserving therapy may be performed • C- Therapy with tamoxifen should start during pregnancy • D- Chemotherapy with doxorubicin or cyclophosphamide can be performed after the first trimester • E- Sentinel node biopsy can be performed with radioactive tracer without ill effects Atypical ductal hyperplasia is: • A- A condition that carries no increased risk for breast cancer • B- a precursor to breast cancer • C- associated with an increased relative risk of breast cancer that is 4-fold higher than the general population • D- associated with an increased relative risk of breast cancer that is similar to a patient with a BRCA mutation • E- is a risk factor for breast cancer only in postmenopausal women Atypical ductal hyperplasia is: • A- A condition that carries no increased risk for breast cancer • B- a precursor to breast cancer • C- associated with an increased relative risk of breast cancer that is 4-fold higher than the general population • D- associated with an increased relative risk of breast cancer that is similar to a patient with a BRCA mutation • E- is a risk factor for breast cancer only in postmenopausal women ENDOCRINE PEARLS

• Thyroid Benign • Adrenal Benign • Workup of thyroid nodule • Incidentaloma • CNBx vs FNA • Pheochromocytoma • Goiter/graves disease • Aldosteronoma • Thyroid malignant • Cortisol Secreting • Papillary (MC) • Adrenal Malignant • Follicular • ACC • Hurthle Cell • MEN syndromes • anaplastic • MEN I • Medullary • MEN Iia/b • Parathyroid Benign • Primary HPT • Secondary HPT • Tertiary HPT • Parathyroid malignant • Parathyroid carcinoma ANATOMY THYROID/PARATHYROID THYROID/PARATHYROID GENERAL PEARLS

Produce T3/T4 in response to TSH TSH best test for function • Blood supply • Superior Thyroid artery from external carotid • Inferior thyroid artery from thyrocervical trunk- blood supply to parathyroids • Venous- drained by superior, middle, inferior thyroid veins • Nerve • Superior laryngeal (external branch) MC injured motor to cricothyroid, close to STA • Recurrent laryngeal- motor to all of larynx • Superior parathyroids- lateral to RLN, above ITA • Inferior parathyroids – medial to RLN, inferior to ITA THYROID

• Benign • Thyroiditis • Hyperthyroidism- Graves, • Hashimotos toxic goiter, toxic nodule • Riedels struma • Medical • Bacterial • PTU/methimazole, beta blocker, • deQuervains lugols • Surgical • Airway compression • Suspicious nodule • Cold nodules • Toxic nodule/Graves unresponsive • Malignant • Procedure • Papillary 85% MC, LN mets • Total thyroidectomy +/- • Follicular- more aggressive, central neck hematogenous • +lateral neck dissection if • Hurthle- oncocytic/oxyphilic positive nodes laterally cells • Radioactive Iodine- >1cm, • Anaplastic- most extrathyroidal dz (not for aggressive, palliative MTC/anaplastic) • MTC- parafollicular c cells, • XRT for medullary, hurthle, calcitonin anaplastic • MEN2a/b, MTC syndromes PARATHYROID

• Function • PTH increases serum Ca++ - increase reabsorption in kidneys, increase vit D, increase bone resorption • Calcitonin- inhibits osteoclasts, increases renal excretion

• Primary • Associated with MENI/IIA • Asymptomatic high PTH/Ca, Cl:PO4 ratio >33, high Urine Ca • OR for symptomatic disease • Asymptomatic disease with Ca >11.6, decreased Cr clearance, nephrolithiasis, osteoporosis, age<50 • MC single adenoma • Multiple adenomas • 4 gland hyperplasia – 3.5 excision (subtotal with autograft) • Pre op localization (ultrasound, sestimibi, 4D CT), 4 gland exploration with intraop PTH and frozen section • Missing glands- search thymus, tracheoesophageal groove, near carotid bifurcation • Secondary • CRF • High PTH in response to low Ca, high PO4 • Total parathyroidectomy with autoimplantation vs subtotal parathyroidectomy • Tertiary • Overproduction of PTH autonomous despite Tx • High PTH and High Ca • Parathyroid Carcinoma • Rare; need radical parathyroidectomy with ipsilateral hemithyroidectomy ADRENAL ANATOMY ADRENAL

• Adrenal Mass Work Up • Adrenal incidentaloma • Mc tumor- met from other primary if previous ca history • No prior hx- nonfunctioning adenoma • R/o function before biopsy • Urine metanephrines • 24hr urine cortisol and ACTH • Serum K, renin, aldosterone • ACC CT/MRI suggest malignancy • FNA if >10 Hounsfield, poor contrast washout, previous CA • Cortical Neoplasms • Cortisol (GFR) • Wt gain, striae, moon face • Aldosterone • Dx: 24h urine cortisol serum ACTH –ACTH low • Hyperaldosteronism cortisol high CT adrenal (Conns) • If ACTH High need high dose • HTN, hypokalemia dexamethasone suppression • Primary- low renin- MC adrenal vs ectopic ACTH adenoma • Adrenal adenoma (3MC cause noniatrogenic hypercortisolism) • Need salt load suppression test- 24h urine aldosterone • Androgens/estrogens- • Aldosterone:renin ratio >20 virilizing –MC malignant • Low K, high Na, metabolic alkalosis • Medullary neoplasms • Pheo • HTN episodic, HA • DX – 24h urine metanephrines, VMA, CT scan, MIBG best at localizing • Rule of 10s • Extra adrenal more likely to be malignant, no epinephrine production • Organ of Zuckerkandl • PREOP- alpha blockade first, volume expand, beta block if necessary ADRENAL

• Surgical Indications • Ominous characteristics • >4-6cm • Functioning • Enlarging • FNA+ ACC • Procedure • Laparoscopic adrenalectomy • Open if very large • Radical adrenalectomy with incidental kidney for ACC MEN SYNDROMES • MENI – correct HPT first • MEN1 gene, menin protein • PTH hyperplasia (1st symptomatic) • Pancreatic islet cell tumors (gastrinoma MC mortality) • Pituitary adenoma - prolactinoma • MENIIA- pheo first if simultaneous tumors • RET • Parathyroid hyperplasia • MTC 99%, 1st symptomatic • Pheo (BL) manage first • MENIIB • RET • MTC- more aggressive • Pheo • Mucosal neuroma/marfanoid SAMPLE QUESTIONS

A 50F underwent FNA of a palpable L thyroid mass suspicious for a follicular neoplasm. She underwent hemithyroidectomy. She has no cervical LAD. Final path confirmed follicular variant of papillary thyroid carcinoma. What is the next step in management? • A-completion thyroidectomy • B- radioactive iodine therapy • C- therapeutic central neck dissection • D- thyroxine therapy • E- systemic chemotherapy SAMPLE QUESTIONS

A patient with resistant HTN on 3 antihypertensive medications and with multiple episodes of hypokalemia has a plasma aldosterone-to-renin ration greater than 50. Adrenal protocol CT demonstrated a 5 cm L adrenal adenoma and a 3 cm R adrenal adenoma. The patient should undergo: • A- I-metaiodobenzyguanidine (MIBG) scan • B- adrenal protocol MRI • C- somatostatin scan • D- adrenal vein sampling • E- percutaneous biopsy of L adrenal mass SAMPLE QUESTIONS

When considering a MRND for well differentiated thyroid cancer, which of the following is true: • A- the superior border of level VI is the laryngeal notch • B- level IA and IB dissection is necessary for papillary cancers in the midline • C- the superior border of level III is at the level of the hyoid • D- the spinal accessory nerve courses through level IV deep to the internal jugular vein • E- the omohyoid muscle courses through level II SAMPLE QUESTIONS