What are the signs/ symptoms of breast cancer in men?

What is the most common presentation?

How is breast cancer in men diagnosed?

What is the treatment?

BENIGN BREAST DISEASE

Breast mass (most are painless), breast skin changes (ulcers, retraction), and nipple discharge (usually blood or a blood-tinged discharge)

Painless breast mass

Biopsy and mammogram

1.Mastectomy

2.Sentinel LN dissection of clinically negative axilla

3.Axillary dissection if clinically positive axillary LN

What is it?

What is the usual age of the patient with this tumor?

Mesenchymal tumor arising from breast lobular tissue; most are benign (Note: “sarcoma” is a misnomer, as the vast majority are benign; 1% of breast cancers)

35–55 years (usually older than the patient with fibroadenoma)

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What are the signs/ symptoms?

How is it diagnosed?

What is the treatment?

What is the role of axillary dissection with cystosarcoma phyllodes tumor?

Is there a role for chemotherapy with cystosarcoma phyllodes?

FIBROADENOMA

Mobile, smooth breast mass that resembles a fibroadenoma on exam, mammogram/ultrasound findings

Through core biopsy or excision

If benign, wide local excision; if malignant, simple total mastectomy

Only if clinically palpable axillary nodes, as the malignant form rarely spreads to nodes (most common site of metastasis is the lung)

Consider chemotherapy if large tumor5 cm and “stromal overgrowth”

What is this tumor’s claim to fame?

Most common breast tumor in women30 years

How is it diagnosed?

What is the treatment for symptomatic fibrocystic disease?

What is done if the patient has a breast cyst?

MASTITIS

Chapter 56 / Breast 417

Through breast exam, history, and aspirated cysts (usually straw-colored or green fluid)

Stop caffeine

Pain medications (NSAIDs)

Vitamin E, evening primrose oil (danazol and OCP as last resort)

Needle drainage: If aspirate is bloody or a palpable mass remains after aspiration, an open biopsy is performed

If the aspirate is straw colored or green, the patient is followed closely; then, if there is recurrence, a second aspiration is performed

Re-recurrence usually requires open biopsy

What are the causes?

What is the most common bacteria?

What is the treatment of breast abscess?

Mammary ductal ectasia (stenosis of breast duct) and mastitis

Nursing Staphylococcus aureus

Nonlactating mixed infection

Antibiotics (e.g., dicloxacillin)

Needle or open drainage with cultures taken

Resection of involved ducts if recurrent Breast pump if breast-feeding

What are the signs/ symptoms of Cushing’s syndrome?

How can cortisol levels be indirectly measured over a short duration?

What is a direct test of serum cortisol?

Truncal obesity, hirsutism, “moon” facies, acne, “buffalo hump,” purple striae, hypertension, diabetes, weakness, depression, easy bruising, myopathy

By measuring urine cortisol or the breakdown product of cortisol,

17 hydroxycorticosteroid (17-OHCS), in the urine

Serum cortisol level (highest in the morning and lowest at night in healthy patients)

In ACTH-dependent Cushing’s syndrome, how do you differentiate between a pituitary vs. an ectopic ACTH source?

Summarize the “Cushing’s syndrome” lab values found in the majority of patients with the following conditions:

Healthy patients

Chapter 57 / Endocrine 421

High-dose dexamethasone test:

Pituitary source—cortisol is suppressed

Ectopic ACTH source—no cortisol suppression

Normal cortisol and ACTH, suppression with low-dose or high-dose dexamethasone ( 1/2)

What is the most common site of ectopic ACTH-producing tumor?

How are the following tumors treated:

Adrenal adenoma?

Adrenal carcinoma?

Ectopic ACTH-producing tumor?

Cushing’s disease?

66% are oat cell tumors of the lung (#2 is carcinoid)

Adrenalectomy (almost always unilateral)

Surgical excision (only 33% of cases are operable)

Surgical excision, if feasible

Transphenoidal adenomectomy

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What medication must be given to a patient who is undergoing surgical correction of Cushing’s syndrome?

Cortisol (usually hydrocortisone until PO is resumed)

What is the incidence of incidentalomas?

4% of all CT scans (9% of autopsies)

What is the most common cause of incidentaloma?

What is the differential diagnosis of incidentaloma?

Chapter 57 / Endocrine 423

Nonfunctioning adenoma ( 75% of cases)

Nonfunctioning adenoma

Pheochromocytoma

Adrenocortical carcinoma

Aldosteronoma

Metastatic disease

Nodular hyperplasia

What is the risk factor for carcinoma?

What is the treatment?

Solid tumor 6 cm in diameter

Controversial for smaller/medium-sized tumors, but almost all surgeons would agree that resection is indicated for solid incidentalomas 6 cm in diameter because of risk of cancer

Which age group is most likely to be affected?

What are the associated risk factors?

Any age (children and adults); average age is 40 to 60 years

MEN-II, family history, von Recklinghausen disease, von Hippel-Lindau disease

What does 131I-MIBG stand for?

How to remember MIBG and pheochromocytoma?

How does the 131I-MIBG scan work?

What is the role of PET scan?

What is the scan for imaging adrenal cortical pheochromocytoma?

Chapter 57 / Endocrine 425

Iodine131MetaIodoBenzylGuanidine

Think: MIBG My Big and thus “My Big Pheo” MIBG Pheo

131I-MIBG is a norepinephrine analog that collects in adrenergic vesicles and, thus, in pheochromocytomas

Positron Emission Tomography is helpful in localizing pheochromocytomas that do not accumulate MIBG

NP-59 (a cholesterol analog)

What is the localizing option if a tumor is not seen on CT, MRI, or I-MIBG?

What is the tumor site if epinephrine is elevated?

What percentage of patients have malignant tumors?

Can histology be used to determine malignancy?

What is the classic pheochromocytoma “rule of 10’s”?

IVC venous sampling for catecholamines (gradient will help localize the tumor)

Must be adrenal or near the adrenal gland (e.g., organ of Zuckerkandl), because nonadrenal tumors lack the capability to methylate norepinephrine to epinephrine

10%

No; only distant metastasis or invasion can determine malignancy

10% malignant

10% bilateral

10% in children

10% multiple tumors

10% extra-adrenal

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How can you remember phenoxybenzamine as a medical treatment of pheochromocytoma?

What is the surgical treatment?

PHEochromocytoma

PHEnoxybenzamine

Tumor resection with early ligation of venous drainage (lower possibility of catecholamine release/crisis by tying off drainage) and minimal manipulation

What are the possible perioperative complications?

Anesthetic challenge: hypertensive crisis with manipulation (treat with nitroprusside), hypotension with total removal of the tumor, cardiac dysrhythmias

In the patient with pheochromocytoma, what must be ruled out?

What is the organ of Zuckerkandl?

CONN’S SYNDROME

MEN type II (almost all cases are bilateral)

Body of embryonic chromaffin cells around the abdominal aorta (near the inferior mesenteric artery); normally atrophies during childhood, but is the most common site of extra-adrenal pheochromocytoma

‘ H yper

AI’

What is the normal physiologic effect of aldosterone?

What are the signs/ symptoms?

What are the two classic clues of Conn’s syndrome?

Classically, what kind of hypertension?

What are the renin levels with Conn’s syndrome?

What percentage of all patients with hypertension have Conn’s syndrome?

Aldosterone causes sodium retention for exchange of potassium in the kidney, resulting in fluid retention and increased BP

Hypertension, headache, polyuria, weakness

1.Hypertension

2.Hypokalemia

Diastolic hypertension

Normal or decreased!

1%