Breast & Endocrine Surgery

The breast mass: triple assessment

Exam, imaging, and tissue. Every palpable breast mass gets triple assessment: clinical exam, imaging, and biopsy. Imaging is age-based because young breasts are dense: under 30, ultrasound first; at 30 and older, diagnostic mammography plus ultrasound. A dominant or suspicious mass needs tissue even if imaging looks benign.

If any one of exam, imaging, or biopsy is suspicious, act on it: a benign-looking mammogram never overrides a suspicious mass.

Core needle over FNA. Core needle biopsy is preferred for a suspicious mass because it preserves architecture and provides ER, PR, and HER2 receptor status; FNA yields only cytology and cannot distinguish invasive from in situ disease. Excisional biopsy is reserved for discordant results.

Breast cancer: surgery and systemic therapy

Breast-conserving therapy pairs lumpectomy WITH radiation; skipping radiation raises local recurrence. The exception: radiation may be omitted in selected women about 65 to 70 or older with a small, node-negative, hormone receptor-positive tumor who take endocrine therapy (local recurrence rises slightly, survival does not change).

Sentinel node spares the axilla. In clinically node-negative cancer, sentinel lymph node biopsy (blue dye plus radiotracer) stages the axilla and spares the lymphedema of a full axillary dissection. Clinically positive or matted nodes going straight to surgery proceed to axillary lymph node dissection. Many node-positive patients now receive neoadjuvant systemic therapy first, and those converted to clinically node-negative can have sentinel node biopsy or targeted axillary dissection instead. After ACOSOG Z0011, a clinically node-negative woman with only 1 to 2 positive sentinel nodes who is having lumpectomy plus whole-breast radiation can skip axillary dissection.

Receptors steer systemic therapy, which is why core biopsy matters:

• ER/PR-positive: endocrine therapy with tamoxifen in premenopausal women (raises endometrial cancer and VTE risk) or an aromatase inhibitor in postmenopausal women (causes bone loss).
• HER2-positive: trastuzumab, with monitoring of cardiac function.
• Triple-negative: chemotherapy.

Thyroid nodules and cancer

Where the risk lives. Hot nodules are almost never cancer; the malignancy risk sits in cold nodules. Suspicious ultrasound features include microcalcifications, hypoechogenicity, irregular margins, and a taller-than-wide shape. Nodules under 1 cm are generally not aspirated, and the size threshold for FNA rises as suspicion falls.

Screen for pheochromocytoma before operating on MEN2-associated medullary thyroid cancer.

After thyroidectomy. Radioactive iodine and TSH suppression follow for higher-risk differentiated cancer. Watch for hypocalcemia from parathyroid injury, hoarseness from recurrent laryngeal nerve injury, and an expanding neck hematoma, which threatens the airway and must be opened at the bedside.

Primary hyperparathyroidism

Usually a single adenoma. Expect high calcium with a high or inappropriately normal PTH and low phosphate; a low urine calcium points instead to familial hypocalciuric hypercalcemia, which is not surgical. Symptomatic disease (stones, bones, abdominal groans) warrants parathyroidectomy.

Numbers trigger surgery in asymptomatic patients:

• Serum calcium >1 mg/dL above the upper limit of normal
• Age under 50
• Osteoporosis (T-score ≤−2.5) or a fragility fracture, including a vertebral fracture on imaging
• eGFR under 60, or kidney stones or nephrocalcinosis
• Hypercalciuria: 24-hour urine calcium >250 mg in women or >300 mg in men

Localize, then operate. The diagnosis is biochemical; a sestamibi scan localizes the adenoma for a focused operation. Afterward, watch for hungry bone syndrome, with hypocalcemia as the skeleton remineralizes.

Adrenal incidentaloma and pheochromocytoma

Is it functional, and could it be malignant? Test function with a 1-mg overnight dexamethasone suppression test (cortisol), plasma or urine metanephrines (pheochromocytoma), and an aldosterone-to-renin ratio if the patient is hypertensive or hypokalemic. Judge malignancy by size and imaging phenotype; a lipid-rich mass (10 HU or less on noncontrast CT) is a benign adenoma.

Resect if the mass is functional, 4 cm or larger, or suspicious for carcinoma on imaging. A small, nonfunctional, benign-appearing mass gets biochemical workup, not biopsy; a clearly benign lipid-rich adenoma (10 HU or less) needs no repeat imaging, while an indeterminate mass is reimaged in 6 to 12 months.

Beta-blockade first risks an unopposed alpha-mediated hypertensive crisis.