Breast Mammary fistula- 2/2 recurrent abscesses from duct obstruction. Associated with smoking - decreased beta carotene - decreased protection of vit A from squamous metaplasia - duct obstruction. Treatment: abx, drainage, then fistulectomy. Subareolar breast abscess Usually in healthy nonlactating women. Damaged, obstructed ducts. S. aureus most common. Dx with US - if thick wall or loculated, may need open I&D. o/w, abx and aspiration successful 85%. Contrast peripheral breast abscesses, which are assoc with comorbidities like DM. Gynecomastia - epithelial ductal hyperplasia and stromal proliferation Puberty 2/2 hormonal changes, adults 2/2 cirrhosis, renal failure, cannabis. Not a risk factor for breast CA Nipple discharge Only worry about bloody, but even bloody is usually intraductal papilloma (single duct) or duct ectasia (multiple). Do physical, mammo. If suspicious (mass) or bloody, biopsy. If no lesion to biopsy, excise the duct from beyond duct up to and including skin. Can do galactography. Bloody discharge from single duct should be biopsied (CA in 10%, higher if assoc with mass). Also get mammo. Diagnosis Screening mammography Recommendation: Starting at 40, every 1-2 years, then annually starting at 50. Ultrasound Factors suggesting malignancy: shape, shadowing, internal echoes, heit/width ratio (architecture): normal is lateral growth, abnormal is taller than wide US categorizes as cysts: sharp, bilat edge shadowing, probable fibroadenoma- sharp and smooth edges, indeterminant, suspicious Breast CA usually indistinct margins and irregular shaowing, heterogenous internal echoes, often taller than wide Stereotactic core bx Contraindication: mammographic radial scar, can't see in the stereotactic suite Fibroadenoma Most common benign tumor of the breast Prophylactic mastectomy - remove nipple-areola complex Option for mod to hi risk - genetic markers/family history - reduces risk by 90% (more in mod than hi risk) Consider for LCIS Male breast CA Risk factors- Klinefelters (47, XXY), African-American, Jewish, obesity, cirrhosis (hi estrogens), BRCA2 (not 1!) 80% ductal, 1% lobular. More likely to be receptor positive compared with women when matched for stage, grade, and age. Treatment similar principles as in women, but more likely to get mastectomy. Adjuvant tx same, men more likely to get hormonal tx, since usually receptor positive. Steroids do not increase risk of male breast CA, but does increase HCC, prostate CA, and renal cell CA. Nipple discharge rare, but often indicative of CA BRCA2 increases risk of breast CA, also prostate, pancreatic, and laryngeal Breast mass during pregnancy US primary test: if asyx simple cyst - observe FNA - fibroadenoma - observe during preganancy, then observe or resect FNA - lactating adenoma- wait until after breastfeeding. Most go away, resect those that do not. Mammo OK in 3rd trimester Management DCIS Lumpectomy or simple mastectomy, maybe XRT (Van Nuys) Don't need axillary dissection - that's for staging, and because it's not invasive, you don't need to look for nodal mets. But, of course, since this is breast disease, sometimes you hould consider it, because breast disease management makes no sense. For instance, SESAP says you should consider if you either have a mass on exam or on mammo. Well, why else would you get a biopsy? Seriously, evaluation of axillary nodes in DCIS (preferably by sentinel node biopsy) should be considered when there is multicentric disease (extensive hi grade DCIS) and you are gonna do a (simple) mastectomy, or if there is suspicion of microinvasion or if there is necrosis. In general, no role for node evaluation or chemo in DCIS. The Van Nuys scoring system gives risk of recurrence without radiotherapy (helps determine if you should give XRT for DCIS). Risk of recurrence: size, histology (comedo or non), margin (positive, <1cm,>1cm) LCIS It's a marker of risk, not a precursor lesion. So surgical removal is not necessary. Risk is about 1% per year, more likely to be ductal than lobular CA, risk equal in both breasts. Options are close follow-up, tamoxifen, or bilateral prophylactic mastectomy - especially if hi risk, like BRCA1/2 positive. If you get a BIRADS-4 mammo, and core biopsy tells you it's LCIS, this is a nonconcordant result (the LCIS does not explain the mammo). You should get more tissue and do a needle loc to see if there is something else. (This is a situation where you get LCIS but you do more surgery). But in general, LCIS does not mandate re-excision for positive margins, XRT, or chemo. Atypical ductal hyperplasia If you didn't get it all out (like if you only did a core biopsy), you gotta get the rest out (excisional biopsy), because the diagnosis is upgraded to DCIS or CA in a significant portion of patients (11-44%). Adenoid cystic carcinoma Rare, good prognosis, does not go to nodes (3%) - don't do ax dissection. Re-excision - high local recurrence. Do simple mastectomy. Tamoxifen For prophylaxis Tamoxifen decreases risk of invasive and noninvasive CA by 50% in patients at hi risk for developing breast CA. Hi risk: 60 or older LCIS Age 35-59 with 5y risk of 1.66% by Gail model - age, 1st degree relatives, menarche (not menopause!), nulliparity or age of first parity, # breast bx, atypical hyperplasia. Options for hi risk If BRCA1/BRCA2: Enhanced screening, tamoxifen, prophylactic mastectomy/oophorectomy Risk for breast (60-80% lifetime) and ovarian CA (15-40% lifetime). BRCA1 may be resistant to tamoxifen (ER/PR negative tumors usually) Sentinel node biopsy Methylene blue - can cause skin necrosis if too superficial Lymphazurin (isosulfan blue) - associated with anaphylaxis, so not methylene blue is used Flase negative rate should be 1-3% Not indicated if node positive by FNA Isolated pulmonary mets after curative resection If pt has already had XRT, further XRT not an option. Open wedge resection give 33% 5y if disease free interval >2y. Isolated hepatic metastasis after curative resection Look hard for other disease (CT.PET) If already had chemo, might not work again If really big, shouldn't do RFA, cryo, or EtOH Resection may give 20% 5y if truly isolated without other disease Locally advanced tumors Greatest risk to life is distant metastatic disease Operation with primary wound closure difficult. Neoadjuvant chemo shinks tumor, allows smaller operation, even BCT. After resection, get XRT and must get more chemo Neoadjuvant chemotherapy Improves rate of BCT. Use if mass too large for lumpectomy and pt wants BCT. Clinical response not a predictor of survival. No dofferences in other things: survival, local control, etc. Breast reconstruction Smokers at increased risk for mastectomy flap necrosis, TRAM flap necrosis, abdominal hernia. "Delay procedure" (ligation of inferior epigastric a), stop smoking 4 wks - can decrease risk. XRT Contraindications: scleroderma or other connective tissue disease of skin, can't get to XRT facility Brachytherapy - hi-dose XRT at lumpectomy site, where 96% of recurrences are. Only 7 days. Eligible if less than 4cm, ductal (not lobular) but not extensive intraductal (cuz then it might go outside the hi-dose area), margins 2-3mm at least, no diffuse microcalcs, 3 or fewer positive nodes. XRT decreases local control, not overall survival, after BCT. Prognosis Node status most powerful predictor In node negative pt, tumor size is next most powerful predictor (after the fact that they are node negative.) Receptor status: ER pos - 10% better 5y (PR positivity predicts response to hormonal tx after recurrence) Male sex: poor prognosis (dx'd later, no difference stage for stage) Women under 35: poorer prognosis after adj for nodes, receptors, histology. Pregnant: poor prognosis - dx'd later. HER-2neu - protein overexpressed in certain breast CAs. Correlated with decreased survival, poorer response to some hormonal and chemo tx, receptor negativity, bad histology. HER-2neu is BAD.

Endocrine Metabolic response to trauma/stress "Glucose intolerance" aka high glucose Increased glycogenolysis in liver and gluconeogensis 2/2 increased glucagon Insulin resistance 2/2 increased cortisol - glucose uptake decreased Insulin concentrations higher Steroids given in acute spinal cord injury and ARDS increase infectious complications. Neuroendocine tumors of pancreas hypervascular ususally indolent radioresistant liver mets not a contraindication to resection of primary (can do wedge resection while at it), don't have to take out mets right away, or at all. Diffuse toxic goiter (Grave's disease) Radioablation is tx of choice Subtotal thyroidectomy less popular - recurrent goiter occurs 10-20% at 10y, 40% at 30y If re-operate for diffuse toxic goiter, increased risk of permanent hypoparathyroidism Substernal goiter - should be resected early (subtotal) to avoid complications - airway obstruction, SVC syndrome, RLN or phrenic n compression. Thyroid storm IVF with glucose (storm accelerates glucose metabolism), steroids (storm causes relative adrenal insufficiency), (ASA worsens storm by displacing T4 from thyroglobulin), B-blockade prevents conversion of T4 to T3, PTU, KI (afterPTU) Intra-op PTH Doesn't affect OR time, cost, stay, morbidity, mortality It does definitively tell you that the abnormal tissue has been removed. Parathyroid CA Rare Presents as hyperparathyroidism Tx: resection of involved gland, ipsilateral thyroid, and regional nodes If recurrent disease, resection usually not curative, but can be used to palliate sx of hypercalcemia If widely metastatic and want to palliate hi Ca - IVF, loop diuretics, bisphosphonates Medullary Thyroid CA Total thyroidectomy + central nod dissection (hyoid to innominate v, between carotids) Papillary thyroid cancer Tx of virtually all papillary or follicular thyroid CA >1.5 cm: total or near total thyroidectomy f/b radioiodine You can ablate an entire lobe with radioiodine, but the radiation required approaches toxic dose, so you limit options for recurrence. Cervical nodal metastases: 50% incidence of micromets to cervical nodes Elective nodal dissection in absence of clinically positive dz not recommended. If lateral nodes detected, modified neck dissection (preserve SCM, spinal accessory, IJ). Don't just remove the enlarged nodes (although that's what Norton does). If nodes appear later (20%), do regional neck dissection then, with no decrease in survival. Node positivity does not impact survival. Node positivity does not affect rate of local recurrence. Risk factor to develop cervical node mets: age > 70, extrathyroid invasion of primary, blood vessel invasion, hi grade Post-thyroidectomy hypocalcemia: risk factors- h/o hyperthyroidism, esp Grave's (hungry bone syndrome), extent of thyroid resection, autotransplantation (takes a while for them to revascularize)