Surgery Oral Exam Review



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Surgery Oral Exam Review:

2005
CASE #1



Hx:

1. HPI of c/c (discharge, painful, etc.)

2. Fam hx-age at dx, # of 1st degree relatives, BRCA 1 or 2 genes

3. Prior mammogram or breast biopsy

4. Menstrual history (early menarche or late menopause)

5. Pregnancy history (1st preg after age 30 or nullparity are both RF’s)

6. Trauma to region - fat necrosis associated with hx of trauma.

7. Hx of HRT

PE:

1. Inspection- 3 positions. Look for asymmetry, dimpling, retraction, etc.

2. Palpate all 4 quadrants of breast and the nipple-areolar complex. Check for discharge.

3. Palpate axillary lymph nodes.

Labs: ?

Radiological Studies:

1. Ultrasound- better for younger women (<30) because they have greater amount of fibrous tissue, which makes mammogram more difficult to interpret.

2. Mammogram - suspicious findings include micro-calcifications, mass, stellate/spiculated patterns.

Ancillary Testing:

1. FNA-if the mass remains, the lesion recurs more than two times or bloody aspirate is obtained, then you must do a biopsy. Dr. Baumann does not recommend doing FNA at all.

2. Core biopsy

3. Mammotome biopsy - if non-palpable. You are using mammography to ensure that you biopsy the lesion.

4. Open biopsy - incisional vs. excisional.

5. Needle loc biopsy

6. Sentinnel node biopsy

Differential Diagnosis:

1. DCIS 3. Invasive lobular ca. 5. Fibrocystic 7. Abscess 9.Ductal ectasia

2. Invasive ductal ca. 4. Fibroadenoma 6. Fat necrosis 8. Intraductal papilloma

Most likely Diagnosis: depends upon the history and histology. In general, I think it is more than likely a pre-malignant/malignant mass.

Non-surgical Management:

1. If its not pre-malignant or malignant, you could just observe and proceed with prior recommended screening.

2. If stage 4 breast ca - chemotherapy alone. CAF (cyclophosphamide, adriamycin, fluorouracil) or CMF (methotrexate). Dr. Baumann also mentioned Taxol.

3. If fibroadenoma or fibrocystic change - just observe.

4. If LCIS - one option is to observe, or you could do a prophylactic bilateral mastectomy.

5. Most individuals with stage 2/3 cancer, also get adjuvant chemotherapy.

6. Only a few patients with stage 1 cancer will get adjuvant chemotherapy.

Surgical Management:

1. Lumpectomy with radiation (breast conservation therapy) - Stage 1-3.

2. Mastectomy (simple or modified radical) - Stage 1-3.
3. Axillary node dissection- if sentinel node biopsy is positive.

There is no survival benefit when doing a mastectomy vs. lumpectomy with radiation in patients with stage 1-3 cancer. Survival/prognosis depends upon the stage.
Other useful points:

In general, a mass must be at least 1 cm to palpate on PE. ½ of breast cancer is located in the upper outer quadrant. Mammogram screening recommendations include a first mammogram between ages 35-40, mammogram every 1-2 years between ages 40-50, yearly mammograms after age 50. Clinical breast exams are recommended every 2-3 years between ages 20-40 and yearly after age 40. Self breast exams should be performed 1 weeks after menstrual period.
Pathology:

1. Inadequate specimen.

2. Benign.

3. Histological risk

a. Hyperplasia

b. Atypical hyperplasia

c. LCIS - this is a biopsy finding. It cannot be palpated on PE or seen on mammography. LCIS increases your risk for breast ca. in both breasts and is a marker for the development of invasive ductal carcinoma, not lobular carcinoma.

4. DCIS - premalignant disease.

5. Invasive cancer

a. Invasive ductal carcinoma

b. Invasive lobular carcinoma

c. Inflammatory breast carcinoma

Other:

Intraductal papilloma is the #1 cause of bloody nipple discharge.

Fibroadenoma - young girl with a solitary smooth, mobile lump.

Fat necrosis - post-traumatic.

Paget’s disease of the skin - indication that there is underlying breast ca.

Case # - 2


This patient would have the same history, physical, etc as the first patient.
Most likely diagnosis: Breast cancer.

This patient is older, has an abnormal mammogram and the lump is located in the upper outer quadrant increasing the likelihood of cancer.
Stage 1-3 disease would warrant a lumpectomy with radiation or a mastectomy.

Stage 4 disease is treated with chemotherapy alone.

Case # - 3


This patient would have the same history, physical, etc. On physical exam, evaluate for a subareolar mass and/or spontaneous nipple discharge.
Bloody nipple discharge is most likely going to be intraductal papilloma or breast ca. This patient is 29 y.o and therefore is much more likely to have intraductal papilloma.
However, you should still get a mammogram because it is bloody discharge and the patient has a family history of breast ca. Very unlikely to be breast ca. Patients who have a family history of breast ca. should receive their 1st mammogram 10 years prior to the age at which the family member was diagnosed.
Treatment: Excision of the affected duct.

Definitive diagnosis is by pathological evaluation of the resected specimen.

4. A 35 yo female presents with a 3x3cm mass in her right thyroid nodule.

Full History: focus on any previous radiation to neck, how rapidly did nodule develop, family history of thyroid problems. Recent h/o viral URI?

Hyperthyroid symptoms: nervousness, fatigue, weight loss, tachycardia, goiter, pretibial myxedema, tremor, heat intolerance, palpitations, fatigue, wt. Loss, dyspnea, weakness, increased appetite, exopthalmos, thyroid bruit, amenorrhea, dec. libido, dec, fertility, HTN.

Hypothyroid Symptoms: fatigue, weight gain, cold intolerance, constipation, menorrhagia, dec libido/fertility, bradycardia, dec. cardiac output, hypotension, SOB from pulmonary effusions, hair loss, enlarged tongue, yellow skin.
Physical Exam: need complete exam, good thyroid eval for nodules. Note size, mobility, firmness, quality/consistency, adherence of mass and if other lymphadenopathy….(worry about hard, fixed gland with cervical lymph nodes)
Tests: Check TSH, Free T3, Free T4, antithyroglobulin and microsomal antibodies, ESR.

Do a FNA(fine needle aspiration) of nodule 1% false + rate and 5% false - rate

Benign (65%)-do US for sizing, check initial thyroglobulin level and follow this number over time.
Suspicious (15%)-get a I123 scan (85% will be cold nodules (cold nodules have 10-15% chance of malignancy), 5% will be hot nodules (hot nodules have a 1% chance of malignancy)

-Surgery is indicated if serial T4 levels do not regress and bx is worrisome
Malignant (5%)-need surgery
Nondiagnositc (15%)

Cystic-drain completely (75% will be cured). If larger than 4cm or complex, or if it recurs after 3 attempts to drain, then evaluate in OR.
Differential dx: tyroiditis or cancer

Acute thyroidits-infections(s. pyogenes, s. aures, pneumococcus), unilateral neck pain and fever, skin erythemia, euthryoid, dysphagia. Mostly spread through lymphatics from nearby infection. Pts often have thyroglossal duct/cyst/fistula

Tx-IV antibiotics and surgical drainage
Subacute/DeQuervain’s thyroiditis- post-viral URI, more in females, fatigue, depression, neck pain, fever, unilateral swelling of thyroid with erythemia, firm and tender thyroid, transient hyperthyroidism then hypothyroid inc ESR.

Tx-self limited disease(w/in 6wks), manage pain with NSAIDs
Chronic/hashimoto’s thryoiditis: Autoimmune (inc risk with down’s, turners, familial Alzheimer’s radiation therapy as kid), painless enlargement of thyroid, neck tightness, firm and rubbery gland, see hypothyroidism other autoimmune disease. Have antithyroglobulin and microsomal antibodies, ab against TSH receptor. In gland see follicular and Hurthle cell hyperplasia, lymphocytic and plasma cell infiltrates

Tx: thyroid hormone, partial thyroidectomy of meds fail.
Riedel’s fibrosing thyroiditis: rare, benign inflammatory thyroid enlargement with fibrosis of thyroid, have painless large thyroid, usually euthyroid, neck pain, possible airway compromise. Need an open biopsy to r/o carcinoma or lymphoma.

Tx: isthmectomy if airway compromise, or medical tx with steroids

Cancer

Papillary(80-85%) inc, risk if had neck radiation. See in pts 30-40 F:M, 2:1, have painless mass, dysphagia, dyspnea, hoarseness, euthryoid. To dx need FNA, CT or MRI to look for invasion. Mass is multifocal, hard, white, with area of necrosis, cystic changes, papillary projections, pale abundant cytoplasm, psammoma bodies with “orphan annie eyes”. Often spreads by lymphatics

TX: if minimal ca: lobectomy or isthmectomy

Other: total or near total thyroidectomy, if +LN do modified radial neck dissection. And I131 ablation for pts with residual thyroid tissue or +LN.

Prognosis: worse for older age and those with distant mets, presence of +LN not affect prognosis. Need post-op thyroid hormone replacement. 10 year survival 95%
Follicular CA(5-10%) see in 50s, and inc risk with dyshormonogenesis, F:M is 3:1. pts have painless rubbery, encapsulated mass that is rarely hyperfunctional. FNA cannot be used for dx, need tissue structure to dx, then CT/MRI to check invasion.

Spreads hematogenously (bone the most common distant site).

Tx: if <2cm do near total thyroidectomy or lobectomy and if >2cm then do total thyroidectomy. For +LN do modified radical neck dissection, and can do I131 ablation for those with residual thyroid or +LN.

Prognosis: worse than papillary, worse in older pts with distant mets, >4cm and high tumor grade.

Variant is the Hurthle cell tumor: bilateral, multifocal, spread to regional LN, arise from follicular cells, mets by lymphatic>hematogenous. Tx same as follicular. 10year survival 70%.
Medullary CA(5-10%) assoc w/MEN in 30-40% of cases. Often pts 50-60yo and M:f 1.5:1. Painful mass, dysphagia, dyspnea, hoarseness. Can dx by FNA (presence of amyloid is diagnostic) and check immunohistochemistry for calcitonin. Often unilateral, in mid-upper lobes, arises from C-cells, see sheets of cells, amyloid and collagen. Mets via lymphatics and locally.

TX: sporadic MTC tx with total tyhroidectomy and median lymph node dissection, modified neck dissection if lateral nodes positive. (poor I131 uptake)

Prognosis: 10 year survival 50-70%.
Anaplastic: 1% inc risk if prior dx of well-differentiated thyroid ca, or iodine deficiency. See in ages 60-70, with M:F 1.5:1. rapidly enlarging neck mass, neck pain, dysphonia, dysphagia, hard fixed LN. Dx by FNA. See macroinvasion, sheets of heterogeneous cells, giant cells, spindle cells. It is very aggressive. 50% have pulmonary mets at dx.

Tx: if small do total thyroidectomy +/- external beam radiation, if airway compromise do debulking surgery and tracheostomy.

Prognosis: poor median survival 4-5months. Most stage IV at presentation.
Remember to follow Ca level after thyroid surgery, b/c damage to parathyriods

5. 45yo male presents to pcp for f/u after recently being hospitalized for a renal calculus. His ca was found to be 14.5. he was feeling fatigued chronically but otherwise has no complaints.

History: complete. Check hypercalcemic sx-kidney stones, bone pain, pathologic fx, n/v, constipation, pancreatitis, PVD, lethargy, confusion, depression, paranoia, gout, wt loss, HTN, polyuria, polydypsia.

Physical exam-complete

DDx of hypercalcemia=CHIMPANZEES

Ca overdose

Hyperparathyroid, hyperthyroid, hypocalciuric hypocalcemia

Immobility

Mets, milk-alkli syndrome

Pagets disease of bone

Addison’s

Neoplasm(colon, lung, breast, prostate, multiple myloma)

Zollinger Ellison syndrome-check gastrin levels

Excessive Vit D/A

Sarcoid-see if secrete acth
Tests: ionized calcium, total calcium, phosphorous, (get Chem-7), Alk phos, TSH, free T3/4,

Look at CT/MRI to check for malignancy, CXR, mammogram…
Primary hyperparathyroidism- 85% are adenomas, 10% are four gland hyperplasias, and cancer <1%. Have overproduction of PTH causing increased absorption of ca from intestine, inc. vit D3 production in kidney, and dec. renal ca excretion, inc. excretion of phosphate and increased break down of bone by osteoclasts(bone resorption)

Tx: initial tx of hypercalcemia by IVF, furosemide(never thiazides!), antiarrythmics if needed.

If solitary adenoma-solitary parathyroidectomy, can bx other glands if enlarged

If multiple gland hyperplasia- do 3 ½ gland parathyroidectomy and re-implant ruminant in forearm or SCM muscle.
Secondary hyperparathyroidism-from chronic renal failure or intestinal malabsorption that causes hypocalcemia with appropriate increase in PTH. Get bone pain from renal osteodystrophy and pruitus, but often asymptomatic.

Tx: in renal failure, restrict phosphorous intake, treat with phosphate binders and ca/vit-D supplements. Adjust dialysate to maximize ca and minimize albumen.
Tertiary: autonomously functioning parathyroid glands resistant to negative feedback. Usually short lived, if persistent, need surgery(31/2 gland parathyroidectomy).
Parathyroid cancer: 40-50% have a PALPABLE firm, fixed mass, an extremely high calcium, high PTH, and high Alkaline phosphatase, bone disease, renal insufficiency, and renal stones

Need to biopsy-path shows pale white, adherent mass, with a thick fibrous capsule and septa, and histo shows enlarged hyperchromic nuclei and varied nuclear size. A common tumor marker is human chorionic gonadotrophin.

Tx: en bloc surgical resection of mass and surround structures, ipsilateral thyroid lobectomy, regional LN, and post-op external radiation therapy and chemo usually not beneficial. 5 yr survival 70%
Post-op complications of parathryoidectomy:

Recurrent laryngeal nerve injury(hoarseness if unilateral or airway obstruction if bilateral)

Neck hematoma

Hypocalcemia(perioral tingling, paresthesia, +chvostek’s sign, +Trousseaus sign, tetany)

Superior laryngeal nerve injury

hungry bone syndrome”-severe hypocalcemia seen after surgical correction of HPTH as chronically ca deprived bones aggressively absorb ca.
6. A 65 year old pt comes to VA b/c of mass in his left neck. On exam he has a 2x2 cm hard but mobile mass in anterior jugular chain. He has no other adenopathy.

History: smoking, alcohol, dysphagia, odynophagia, hoarseness, stridor, globus(feel like have lump in throat), speck d/o, referred ear pain (cn V IX X)
Physical: do full head and neck exam,

Tests: direct laryngoscopy, CT/MRI to look for primary, FNA for tissue diagnosis, bx contraindicated b/c it adversely affects survival if cancer.
DDx:Inflammatory: cervical lymphadenitis, cat scratch disease, infectious mono, infection

Congenital: thyroglossal duct cyst(midline, elevates with tongue protrusion), branchial clefts(lateral), dermoid cyst(midline, submental), hemangioma, cystic hygroma.

Neoplastic-primary or metastatic(hodgkins/nonhodgkins lymphoma), squamous cell ca.
Tx: surgical excision for congenital or neoplastic(radical and modified neck dissection)

Radical neck dissection: removal of all nodes from clavicle to mandible, SCM, Submandibular gland, tail of parotid, IJ vein, digastric muscle, stylohyoid, omohyoid, fascia in ant/post triangles, cn XI, and cervical plexus sensory nerves.

Do this when clinically + nodes that likely contain ca, clinically - nodes in neck, but high probability of mets from primary tumor elsewhere, a fixed cervical mass that is respectable

Contraindications: distant mets, fixation to structure that cannot be removed, low neck mass.
Usual etiology in adults is cancer

CASE # 7 (Esophagus)
Hx:
1. 55 yo male 5. 5 lb weight loss in 3 weeks
2. chronic EtOH use
3. difficulty swallowing
4. food gets stuck in mid chest, needs to drink to let it pass
PE:
1. Cachetic
2. Supraclavicular lymphadenopathy
3. May be entirely normal if early in disease
Labs:
1. LFTs (liver mets)
Radiological Studies:
1. UGI- localizes tumor 3.Transesophageal US
2. EGD- obtains biopsy, assesses resectability 4. Barium swallow
5. CT chest/abdomen
Ancillary Testing:
1. CXR (lung metastasis or hilar LAD) 2. bone scan (bone mets)
Differential Diagnosis:
1. Esophageal carcinoma 4. Diffuse esophageal spasm 7. Foreign body
2. Benign stricture 5. Lymphoma 8. Inflammation
3. Achalasia 6. GERD 9. Extrinsic compression

Most likely Diagnosis:


Esophageal carcinoma (squamous cell cancer in most of esophagus or adenocarcinoma at GE junction)


Non-surgical Management:
1. Radiation
2. Chemotherapy
Surgical Management:
1. Total thoracic esophagectomy with gastric pull-up or colon interposition
2. Endoscopic laser therapy
3. Endoscopic dilatation and stent placement
4. Placement of gastrostomy or jejunostomy tube
Other useful points:
Most common in 6th decade, men>women, etiologic factors: tobacco, EtOH, diets high in nitrites or nitrosamines, GE reflux, Barrett’s esophagus, achalasia, chronic esophagitis, Plummer-Vinson syndrome, see Recall pg 604 for staging


CASE # 8 (Esophagus)
Hx:
1. 49 yo male 4. obesity
2. polish sausage stuck in chest 5. mild chest discomfort
3. dysphagia 6. heartburn
PE:
1. obese pt.
Labs:
1. CBC
2. LFTs
Radiological Studies:
1. Barium swallow
2. EGD (must evaluate for malignany)
Ancillary Testing:
1. CXR
2. bone scan
Differential Diagnosis:
1. Benign stricture 3. Extrinsic compression 5. Esophageal diverticula
2. Diffuse esophageal spasm 4. Esophageal CA 6. Achalasia
Most likely Diagnosis:
Benign stricture (inflammation due to long-standing GERD)


Non-surgical Management:
1. Adjust/change medications for GERD (antacids, H2 antagonists, PPIs)
Surgical Management:
1. Endoscopic dilatation (with polish saugagectomy???)
2. Esophagectomy with colon interposition or gastric pull-up
Other useful points:
Etiologic factors: long-standing GERD, radiation esophagitis, infectious esophagitis, corrosive esophagitis, subsequent to scleropathy for bleeding ulcers; most feared complication of dilatation is esophageal rupture


CASE # 9 (Esophagus)
Hx:
1. 40 yo female
2. chronic heartburn, occurs late at night and wakes her up at night
PE:
1. Normal appearing female
Labs:
1. CBC
2. Cardiac enzymes
Radiological Studies:
1. Barium swallow (assess severity, look for anatomical cause)
2. EGD (evaluate mucosa, obtain biopsies)
Ancillary Testing:
1. Continuous pH monitoring 3. EKG
2. Esophageal motility study
Differential Diagnosis:
1. GERD 3. Hiatal hernia 5. Benign stricture
2. Barrett’s esophagus 4. Gastric outlet obstruction 6. Angina/CAD
Most likely Diagnosis:
GERD (chronic)
Non-surgical Management:
1. H2 antagonists, Antacids, PPIs , metoclopramide
2. Smoking cessation
3. Sleep w/ head of bed elevated
4. Small, multiple meals
Surgical Management:
1. Nissen (lap or open)- wrap fundus all the way around esophagus
2. Belsy Mark IV- wrap is not all the way around
3. Hill- tighten arcuate ligament around esophagus and tack stomach to diaphragm
4. Lap Toupet- less wrap used with decreased esophageal motility
Other useful points:
Etiologic factors: decreased LES tone or esophageal motility, hiatal hernia, gastric outlet obstruction, NGT; complications that require surgery: failure of medical therapy, esophageal strictures, progressive pulmonary insufficiency secondary to nocturnal aspiration, Barrett’s esophagus


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