SURGERY

BENIGN TUMORS AND CYSTS S 1 EPIDERMAL

2 TRICHILEMMAL
3 DERMOID CYST
Recall: Layers of the Skin Type CYST (PILAR or
INCLUSION CYST (Congenital Inclusion)
Isthmust-Catagen)
1. Epidermis – outermost layer
Most common 2nd most common
Types of cells: Frequency
cutaneous cyst cutaneous cyst
-
• Keratinocytes (squamous cells) – ectodermal origin Congenital (early onset):
− Principal cells of the dermis epithelium trapped during
May be hereditary
− Synthesize keratin: midline closure
Characteristics - (autosomal
(1) Forms the surface coat of the epidermis dominant)
May be attached to
(2) Structural protein of hair and nails underlying structures (e.g.
pleura, CNS)
• Melanocytes – pigment producing, neural crest origin
Most common:
• Langerhans cells – immunologic fxn, bone marrow origin face, neck,
− Recognize, uptake, process, and present antigen to T- Most common: eyebrow
trunk
lymphocytes Site Scalp of females Anywhere from nasal tip to
May be found
forehead
− Found among keratinocytes of the stratum spinosum anywhere in the
− Folded nucleus and distinct intracytoplasmic organelles body
called Langerhans or Birbeck granules Squamous epithelium,
eccrine glands,
• Merkel cells Mature Outer layer
pilosebaceous units, may
− Slow adapting touch receptors Composition
epidermis with resembles root
contain bone, tooth, nerve
− Found in the basal layer of the palms and soles, oral and complete sheath of a hair
tissue; lining may have
granular layer follicle
genital mucosa, nailbeds, follicular infundibula eosinophilic (shark tooth)
− Paranuclear whorl of intermediate keratin fibers pattern
− Connect with adjacent keratinocytes by desmosomes
Zones:
Sample
(1) Basal layer (Stratum germinativum) – innermost layer
(2) Malpighian or Prickle layer (Stratum spinosum)
(3) Stratum lucidum – clear to pink layer in the palms and soles, • Complication: Inflamed cysts
formed in response to scratching or rubbing − Ruptured cysts become firmly adherent to surrounding structures
(4) Granular layer (Stratum granulosum) à more difficult to remove
(5) Horny layer (Stratum corneum) − Induce a vigorous foreign body inflammatory response
2. Dermis − Symptoms: sudden onset of redness, pain, swelling, local heat
• Collagen – principal component, major structural protein for the − Sign: I&D – smelly, cheesy material
entire body − Antibiotic treatment NOT required (sterile)
• Smooth muscle − IL Triamcinolone may hasten resolution
− Arrectores pilorum (hair) • Management
− Tunica dartos (scrotum) − Incision and drainage is curative but complete cyst, daughter
− Areola (nipples) cysts, entire cyst wall must be removed to prevent recurrence
• Meissner corpuscles
− Touch and pressure sensor SOFT TISSUE TUMORS
− Found on the digits, palms, soles 2 ACROCHORDON 3
Type 1 LIPOMA
• Vater-Pacini corpuscles (Skin tags) DERMATOFIBROMA
− Touch and pressure sensor Most common
Frequency - -
− Weight bearing portions and genitalia subcutaneous neoplasm
Soft, fleshy,
• Mast cells Soft, fleshy,
compressible Soft, solitary, small
− Spindle shaped, hyperchromatic Characteristics
Solitary or multiple
pedunculated
(1 – 2 cm)
− Has receptors for IgE Usually small
May grow to large size
3. Panniculus (Subcutaneous tissue) Pre-auricular areas,
Most common on trunk
• Functions: Site
May occur anywhere
axillae, trunk, Legs and flanks
− Provides buoyancy eyelids
− Repository of energy Hyperplastic Unencapsulated
Lobulated tumor
epidermis over a connective tissue
− Endocrinologic function: site of hormone conversions Histology composed of normal fat
fibrous connective whorls with
(1) Androstenedione + Aromatase à Estrone cells
tissue stalk fibroblasts
(2) Produces Leptin Excisional biopsy if
with atypical
presentation
Observation or surgical “Tying off” or
Management Surgical removal is
excision resection
TOC
Or conservative
management

Sample

BENIGN CYSTS AND TUMORS OF THE HANDS

Type 1 GANGLION CYST 2 LIPOMA 3 ENCHONDROMA
Most common 1°
Most common soft tissue Common tumor
Frequency bone tumor of the
tumor of the hand of the body
hand (> 90%)
CUTANEOUS CYSTS – “Sebaceous cyst:” misnomer, contains keratin
Mucinous, fluid-filled
• Clinical presentation – subcutaneous, firm, thin-walled, compressible, Overgrowth can Usually benign but
pseudocysts arising from
freely movable nodule containing a white, creamy material (cheesy cause local bony
synovial linings of irritated
Characteristics neurologic destruction can
consistency, pungent odor) with smooth and shiny overlying skin due to and inflamed joints,
changes due to lead to pathologic
upward pressure attached to the normal skin above by a comedo-like ligaments, tendon sheaths
compression fracture
central infundibular structure or punctum without epithelial lining
Dorsal wrist (common), Proximal phalanges
• Histology
Sites volar wrist, flexor tendon (common),
− Epidermis growing into the center (mature cells) of the cyst sheath, dorsal DIP joint metacarpal bones
− Desquaminated cells (keratin) collect in the middle to form cyst Aspiration of cyst provides X-ray: well-defined
See above
• Etiopathogenesis only temporary relief radiolucent lesion
− Due to plugging of follicular orifice (common) Management Definitive: surgical excision in diaphysis or
− Epidermal implantation (e.g. via penetrating trauma) of stalk and debridement metaphysis with
of synovial origin sclerotic rim

Life is what you make it. Vita qua se facies est! 1

 • Clinical manifestations:
− Usually slow growing and well circumscribed
Sample See above 1. Parotid: pre-auricular mass
2. Submandibular: neck mass
3. Sublingual: floor of the mouth mass
*Perform: Bimanual palpation of the tongue
Type
4 GIANT CELL TUMOR OF 5 GIANT CELL TUMOR 6 PYOGENIC 4. Minor salivary gland: painless submucosal masses between
THE TENDON SHEATH OF THE BONE GRANULOMA the hard and soft palate
2nd most common tumor Common in 20’s – − Malignant:
Frequency -
of the hand 40’s
1. Rapid growth
Painless, asymptomatic
Arises from tendon
2. Pain or paresthesias
sheath Painful 3. Facial nerve weakness (Parotid)
Discrete, nodular, Expanding mass Solitary, raised, 4. Skin invasion
polypoid, lobulated, from epiphysis hyperemic, 5. Fixation to the mastoid tip
slow-growing masses leading to cortical ulcerative lesions 6. Trismus (masseter, pterygoids)
Characteristics
affecting the digits, firmly destruction then Due to trauma • Recall: Facial nerve
fixed with freely mobile fracture with infection or
overlying skin (+) Multinucleated inflammation
Due to reactive giant cells
hyperplasia associated
with inflammation
DIP (common), volar Distal radius
Sites aspect of hand and (common), -
fingers phalanges
Intralesional Marginal excision
curettage with Alternative:
Management Marginal excision adjuvant cryosurgery shave off lesion,
and bone cement flush skin,
packing coagulate base

Sample

• Recall: Lymphatic drainage of the neck

− Oral cavity and lip à Levels I, II, III
BENIGN NECK MASSES − Oral tongue à Levels III, IV
Type
1 THYROGLOSSAL DUCT 2 BRANCHIAL 3 LYMPHANGIOMA − Oropharynx, hypopharynx, larynx à Levels II, III, IV
CYST CLEFT CYST (CYSTIC HYGROMA) − Nasopharynx and thyroid à Level II, III, IV, V
Branchial cleft − Hypopharynx, cervical esophagus, thyroid à Level VII
apparatus persists
− Delphian node: Pretracheal LN involved in glottic and subglottic
Vestigial reminder of after fetal
tract of descending development Lymphatic tumors
thyroid gland from • First BCs – EAC, malformation
Definition foramen cecum (at parotid gland secondary to
tongue base) into lower • Second & Third obstruction of normal
anterior neck during fetal BCs – anterior drainage
dev’t border of SCM
with tract to
skin
• 2° infection • Mobile, fluid-filled
• Occurs after URTI leads to masses
Characteristics resulting to enlarged enlargement, • Extensively track
or infected cyst cellulitis, into surrounding
abscess soft tissues
• Difficulty nursing
• Midline or
• Smooth, round, • Facial or neck
paramedian cystic
non-tender distortion
mass adjacent to LEVEL LYMPH NODES
• Large: • Respiratory distress
Manifestations hyoid bone I Submental and Submandibular nodes
dysphagia, • Loculated,
• Rise and fall with Submental nodes: medial to the anterior belly of digastric bilaterally, symphysis
stridor, shiftable, Ia
larynx upon of mandible superiorly, hypid inferiorly
dyspnea compressible
swallowing Submandibular nodes: posterior to the anterior belly of digastric, anterior to
• Transilluminate Ib
• Pre-op: UTZ performed posterior belly of digastric, inferior to body of mandible
to ensure there is II Upper Jugular Chain nodes
normal thyroid tissue in Jugulodigastric nodes: deep to SCM, anterior to posterior border of SCM,
the lower neck, Lab IIa posterior to posterior belly of digastric, superior to hyoid, inferior to Spinal
assay to assess if accessory nerve (CN XI)
euthyroid Remove fistula IIb Submandibular recess: superior to Spinal accessory nerve to level of skull base
Management • Sistrunk procedure: tract to the point Surgical removal Middle Jugular Chain nodes: inferior to hypoid, superior to cricoid, deep to SCM
III
removal of cyst, tract, of origin from posterior border of SCM to strap muscles medially
central portion of Lower Jugular Chain nodes: inferior to cricoid, superior to clavicle, deep to SCM
IV
hyoid bone + removal from posterior border of SCM to strap muscles medially
of part of tongue V Posterior triangle nodes
base up to foramen Lateral to posterior of SCM, inferior and medial to Splenius capitis and Trapezius,
cecum Va
superior to Spinal Accessory nerve
Lateral to posterior of SCM, medial to Trapezius, inferior to Spinal Accessory
Vb
nerve, superior to clavicle
Sample Anterior Compartment nodes:
VI Inferior to hyoid, superior to suprasternal notch, medial to lateral of strap muscle
bilaterally
Paratracheal nodes:
VII
SALIVARY GLAND TUMORS Inferior to suprasternal notch in upper mediastinum
• Epidemiology: • Diagnosis
− Relatively uncommon (< 2% of head and neck neoplasms) − MRI: most sensitive study to determine soft-tissue extension and
− 85% are from the Parotid gland involvement of adjacent structures
*Most common: Pleomorphic adenoma (Benign mixed tumor) − FNA: accurate preoperative diagnosis in 70 – 80% of cases
− 50% of Submandibular and Sublingual glands are malignant • Treatment
− 75% of Minor salivary gland tumors are malignant − Surgical excision of affected gland
− Most common malignant: Mucoepidermoid CA − Parotid gland: excision of superficial lobe with Facial nerve
− Second most common: Adenoid cystic CA dissection and preservation

Life is what you make it. Vita qua se facies est! 2

 − Submandibular gland: resection of gland, submental and BREAST MASS S
submandibular laymph nodes Recall: Breast Anatomy
− Radical resection for tumors that invade: • Lobules organized into 15 – 20 lobes
1. Mandible • Cooper’s suspensory ligaments
2. Tongue − Fibrous bands of connective tissue inserted perpendicularly into
3. Floor of mouth the dermis that provide structural support
− Therapeutic removal of regional lymphatics: • Normally extends from the level of the
1. Clinical adenopathy 2nd or 3rd rib to the inframammary fold at
2. Risk for regional metastasis > 20% the 6th or 7th rib, and transversely from
the lateral border of the sternum to the
TYPES anterior axillary line
A. Benign Epithelial Tumors • Posterior surface rests on the fascia of the
1. Pleomorphic adenoma (80%) pectoralis major, serratus anterior, and external
2. Monomorphic adenoma oblique abdominal muscles and upper extent
3. Warthin’s tumor of the rectus sheath
4. Oncocytoma • Axillary tail of Spence – extends laterally
5. Sebaceous neoplasm across the anterior axillary fold
B. Nonepithelial Benign Lesions • Upper Outer Quadrant of the breast contains greatest volume
1. Hemangioma • Areola – pigmented; sebaceous, sweat, accessory glands
2. Neural Sheath Tumor • Montogomery’s tubercles – small elevations on the surface of the area
3. Lipoma produced by glands
• Blood supply:
REFERENCES: 1. Perforating branches of the internal mammary artery
1. Brunicardi, C.F., et al. (2010). Schwartz’s Principles of Surgery, 19th ed. *With the 2nd, 3rd, and 4th anterior intercostal perforators arborize in
McGraw-Hill Companies Inc.: New York. the breast as the medial mammary arteries
2. James, W.D., et al. (2006). Andrew’s Diseases of the Skin: Clinical 2. Lateral branches of the posterior intercostal arteries
Dermatology, 10th ed. Saunders Elsevier Inc.: Canada. 3. Branches from the axillary artery:
3. Jarrell, B.E., et al. (2008). National Medical Series for Independent Study: a. Highest thoracic branches of thoracoacromial a.
Surgery, 5th ed. Lippincott Williams & Wilkins: Baltimore. b. Lateral thoracic branches of thoracoacromial a.
Also gives off branches to supply:
c. Pectoral branches branches of thoracoacromial a.
• Venous drainage:
1. Perforating branches of the internal thoracic vein
2. Perforating branches of the posterior intercostal veins
3. Tributaries of the axillary vein
4. Batson’s vertebral venous plexus: invests vertebrae, extends from
the base of skull to sacrum à possible route for breast cancer
metastases to vertebrae, skull, pelvic bones, and CNS
• Nerve supply:
− Sensory innervation:
1. Lateral mammary branches – lateral cutaneous branches of
the 3rd to 6th intercostal nerves
2. Anterior branches of the supraclavicular nerve (cutaneous
branches from the cervical plexus) – skin over the upper
portion of the breast
3. Intercostobrachial nerve (lateral cutaneous branch of the
2nd intercostal nerve) – resection causes loss of sensation
over medial aspect of upper arm
• Lymphatic drainage:
LI – lateral/below lateral border pectoralis minor
LII – superficial/deep to pectoralis minor
LIII – medial/above upper border pectoralis minor
*Arrows show direction of flow

SIX AXILLARY LYMPH NODE GROUPS – > 75% of lymph drainage

*25% drain to the parasternal (internal mammary) group of LNs  
LEVEL GROUP COMPOSITION DRAINS

Axillary vein
4 – 6 lymph nodes medial or
group Upper extremity
posterior to the vein
(Lateral)

External
I 5 – 6 lymph nodes along the
mammary
lower border of the pectoralis Lateral aspect of the
group
minor contiguous with the lateral breast
(Anterior/
thoracic vessels
Pectoral)
5 – 7 lymph nodes along the
Scapular group posterior wall of the axilla, at the Lower posterior neck,
(Posterior/ lateral border of the scapula posterior trunk,
Subcapsular) continguous with subcapsular posterior shoulder
vessels
Axillary vein, external
3 – 4 lymph nodes embedded in mammary and
Central group the axillary fat, immediately scapular lymph
posterior to the pectoralis minor nodes, directly from
II
the breast
Interpectoral 1 – 4 lymph nodes between the
Directly from the
group (Rotter’s pectoralis major and minor
breast
nodes) muscles
6 – 12 lymph nodes posterior and
Subclavicular All other groups of
III superior to the upper border of
group (apical) axillary lymph nodes
the pectoralis minor

Life is what you make it. Vita qua se facies est! 3

EVALUATION OF BREAST PROBLEMS 7. Biopsy
1. Self Breast Examination at 20 years old a. Fine Needle Aspiration (FNA) – useful for palpable lesions
• Monthly, ideally just after menses (1) Cyst aspiration: diagnostic and therapeutic
• With hands on sides, inspect for changes in size, shape, color, − Drain cyst completely, fluid must be nonbloody
distortion, swelling, dimpling, puckering, bulging of skin, inverted − If bloody, consider excision to rule out malignancy
nipple, redness, soreness, rash (2) Solid: extract cells for cytologic examination
• With arms raised inspect again − (+) Atypia: do excision biopsy
• While supine, use finger pads of contralateral hand with fingers flat − Confirmed malignancy: further surgery necessary
and together to feel breast using a circular motion from top to b. Core Needle Biopsy – for palpable solid lesions
bottom (collar bone to abdomen) then side to side (armpit to c. Incisional Biopsy – for diagnosis of inflammatory BC, big lesions
cleavage) d. Excisional Biopsy (Gold standard for small lesions)
• Repeat palpation while standing − Completely removes a lesion, ensure adequate margins
2. Consultation Breast Examination every year after 30 years old − Can be done with local anesthetic with mild sedation
• Inspection – first with arms on the side, then arms straight up in the e. Non-palpable radiographic abnormalities
air, then with hands on the hips (1) Needle-guided Biopsy
− Symmetry − Excise lesion after radiologist places localizing wire in
− Size breast to identify site
− Shape − Visualization of lesion on 2 mammographic views
− Edema (Peau d’orange) required to allow accurate needle placement
− Nipple or skin retraction (2) Stereotactic or Mammotome Biopsy
− Drainage − Accurate and less invasive
− Erythema − Deploy core needle into mammographic abnormalities
• Palpation using computed mammographic equipment
− Supine position with a pillow supporting ipsilateral hemithorax − Indications:
− Palpate breast from ipsilateral side, examine all quadrants o Small nonpalpable radiodensities
− Use palmar aspect of fingers, avoid grasping or pinching o Single or multiple foci of calcifications
− Systematic lymphadenopathy search: axillary, clavicular, o Lesions seen on only one mammographic view
parasternal o Lesions adjacent to breast implants
− Characteristics of palpable mass:
(1) Location COMMON BREAST COMPLAINTS
(2) Size and shape BREAST TENDERNESS
(3) Consistency • More common in premenopausal (reproductive age)
(4) Mobility or Fixation − Breasts usually full and edematous prior to menstruation
3. Screening mammography – used to detect breast cancer in − Estrogen (monthly menstrual cycle) à Inflammation of breast à
asymptomatic with high risk (30 – 39 years old) Withdrawal of estrogen à Scarring à Fibrocystic change
4. Baseline mammography at 40 years old • Approach:
• Hallmark – speculated density with ill-defined margins Normal variant BREAST TENDERNESS Abscess
• Two views:
− Craniocaudal: better visualization of medial aspect, allows  
greater breast compression Normal variant: Fibrocystic change: Abscess:
− Mediolateral oblique: images greatest volume of breast Normal mongo seed Signs of
palpation feel/bumps, due to inflammation
tissue, including UOQ and axillary tail of Spence
estrogen stimulation
• Consult doctor for need of regular mammographic screening
between 40 to 50 years old
• Annual mammography thereafter – or earlier in patients with Normal variant History and PE: Normal Abscess
higher risk
• Diagnostic mammography – evaluate patients with abnormal  
findings (breast mass, nipple discharge, etc.) Patient < 35 y/o History and PE: Normal Patient ≥ 35 y/o
− Uses CC, MLO views with:  
(1) 90-degree lateral view + CC: triangulate exact location
Reassurance Normal Mammogram
of abnormality
(2) Spot compression: resolve calcifications and margins  
− Can be used to guide interventional procedures (e.g.
Patient < 35 y/o History and PE: Normal Persisting pain
needle localization, needle biopsy)
• Findings on mammography:  
− Solid mass with/without stellate features Patient < 35 y/o Pain relievers
History and PE: Normal
− Asymmetric thickening of tissues
− Clustered microcalcifications  
− Microcalcifications in and around suspicious lesion Danazol: Anti-follicle
5. Ultrasound Patient < 35 y/o History and PE: Normal stimulating hormone
• Used to guide biopsy and needle localization of lesion
NIPPLE DISCHARGE
• Second most frequent breast imaging tool
• Bloody – most commonly due to malignancy, 2nd: intraductal papilloma
• Can further characterize abnormalities seen on mammogram or
• Approach:
found on PE (i.e. cyst vs. solid mass)
• Breast cysts (benign) – well-circumscribed, smooth margins, echo- Normal variant NIPPLE DISCHARGE Abscess
free center  
• Solid mass: BENIGN MALIGNANT
− Benign breast masses: smooth contours, round, or oval Bilateral Unilateral
shapes, weak internal echoes, well-defined anterior and Clear, white, yellow, green Bloody with a mass
posterior margins Occurs with compression Occurs spontaneously
− Breast cancer: irregular walls, smooth margins, acoustic Multiple ducts Single duct

6.
enhancement
Magnetic Resonance Imaging
History
and
 
• Sensitive but not specific for breast evaluation PE:
Patient > 35 y/o Normal
History Localization and Biopsy
• Useful in patients with:
− Mammographically dense breasts and
PE:
 
− Axillary disease Normal
− Negative mammogram Negative Positive Localization and Biopsy
• Other uses:
− Can detect extent of tumor within breast  
− Can detect residual tumor within breast after lumpectomy Negative Positive Benign Malignant
− Can differentiate between tumor and postsurgical scar
Life is what you make it. Vita qua se facies est! 4
BREAST MASSES 2. Mycotic infections
• Work-up depends on age at presentation • Etiology
− Post-menopausal women: most prone to carcinoma (excise) − Blastomyces
− Women younger than 30 years old: most lesions benign (observe) − Sporothrix schenckii
− Pre-menopausal: between 30 years old and menopause: “Gray − Suckling infant inoculates intraoral fungi to nipple-areola
area” (observe/excise) complex
• Approach: • Presentation
− Mammary abscess in close proximity to nipple-areolar
complex
− Seropurulent material expressed
• Management
− Antifungal agents
− Drainage of abscess
− Partial mastectomy
• Candida albicans
− Erythematous, scaly lesions of the inframammary or axillary
folds
− Scrapings: filaments and binding cells
− Management
(1) Remove predisposing factors, e.g. maceration
(2) Topical nystatin
3. Hidradenitis suppurativa
• Nipple-areola complex or axillary chronic inflammatory condition
originating from the accessory areolar glands of Montgomery or
axillary sebaceous glands
• Predisposing factor – chronic acne
• Management
BREAST IMAGING REPORTING AND DATABASE SYSTEM (BI-RADS) − Antibiotic therapy
CATEGORY ASSESSMENT FOLLOW-UP RECOMMENDATIONS − Incision and drainage
Routine annual screening mammography for − Excision
1 Negative
women over 40 years old − Advancement flaps or split-thickness skin grafts
2 Benign
Routine annual screening mammography for 4. Mondor’s disease
women over 40 years old • Thrombosis of the superficial veins of the anterior chest wall and
3 Probably Benign Initial short-term follow up (6 months) examination breast
Suspicious
4 Usually requires biopsy − Frequently involved veins:
abnormality
Highly suggestive of
(1) Lateral thoracic vein
5 Requires biopsy or surgical treatment (2) Thoracoepigastric vein
malignancy
Known Biopsy- Lesions identified on imaging study with biopsy (3) Superficial epigastric vein
6
Proven malignancy proof of malignancy prior to definitive therapy • Acute pain in the lateral aspect of the breast or anterior chest
wall
INFECTIOUS AND INFLAMMATORY DISORDERS • Tender, firm, cord-like structure following the distribution of the
May be intrinsic (breast) or extrinsic (adjacent structures) major superficial veins
1. Cellulitis/Mastitis/Breast abscess • Indications for biopsy:
• Etiology − Uncertain diagnosis
− Staphylococcus aureus: localized, deep − Mass present near tender cord
− Streptococcus: diffuse, superficial • Management
• Presentation − Benign and self-limited (4 – 6 weeks)
− Point tenderness, erythema, hyperthermia − Anti-inflammatory medications
− Occur within first few weeks of breastfeeding − Application of warm compress along vein
− May result to abscess in the ff. areas: − Restriction of motion of ipsilateral extremity and shoulder,
(1) Subcutaneous brassiere support of breast
(2) Subareolar − Excision of involved vein segment: when symptoms persist or
(3) Interlobular/periductal are refractory to therapy
(4) Retromammary
• Pre-op ultrasound: delineate required extent of drainage BENIGN LESIONS OF THE BREAST
• Management: 1. Fibrocystic disease (Chronic Cystic Mastitis)
− Drainage via circumareolar incisions/incisions parallel to • Broad term for various benign breast changes characterized by
Langer’s lines nodularity with or without pain
− Biopsy of abscess cavity wall at the time of I/D: to rule out • Presentation:
underlying breast CA or necrotic tumor − Breast tenderness
− Local wound care − Older women
(1) Application of warm compress − Nevus on breast
(2) Administration of IV antibiotics • Result of prolonged cyclic stimulation of repeated menstrual cycle
(a) Penicillins • NOT premalignant EXCEPT those with atypical hyperplasia
(b) Cephalosporins • Diagnosis:
• Chronic/recurrent abscess − History and PE
− Culture: identify acid-fast bacilli anaerobes, aerobes, fungi, − Mammography
uncommon organisms − Biopsy
• Hospital-acquired puerperal infections • Treatment:
− Milk stasis or non-infectious inflammation − Reassurance and pain management
− Epidemic puerperal mastitis: − Aspiration of cystic lesion
MRSA transmitted via suckling neonate − Proven effective by RCT:
Purulent fluid expressed from nipple (1) Caffeine free diet
− Non-epidemic/sporadic puerperal mastitis: (2) Abstinence from smoking
Interlobular connective tissue involvement (3) Danazol
Nipple fissuring, milk stasis, retrograde bacterial infection 2. Fibroadenomas
− Management: • Predominantly in younger women (15 – 25 years old)
(1) Breast suction pump • 1 – 2 cm diameter, stable but may enlarge
(2) Antibiotic therapy − Disorder: large fibroadenomas (≤ 3 cm)
(3) Surgical therapy − Disease:
• Zuska’s disease (recurrent periductal mastitis) (1) Giant fibroadenomas (> 3 cm)
− Recurrent retroareolar infections and abscesses (2) Multiple fibroadenomas (> 5 lesions/ breast)
Life is what you make it. Vita qua se facies est! 5
 • Histologically normal cellular elements, abundant stroma Screening and risk factor management
• Mobile and well circumscribed • Mammography
• Hormonal dependence (estrogen) similar to normal breast − Routine screening for women ≥ 50 years old reduces mortality
− Lactate in pregnancy from breast cancer by 33%
− Involute in postmenopausal period − Controversial for women < 50 years old:
• Diagnosis: ultrasound with core-needle biopsy 1. Breast density is greater, less likely to detect early breast CA
− Features on ultrasound 2. More false-positive test findings, resulting to unnecessary
(1) Oval biopsies
(2) Width larger than AP diameter 3. Younger women less likely to have breast cancer
(3) Gentle lobulations (< 4) • Chemoprevention – selective estrogen receptor modulators, reduce
(4) Well circumscribed margins breast cancer risk by 50%
(5) Homogenous internal echogenicity − Tamoxifen: also reduces incidence of LCIS and DCIS, but with
(6) Thin echogenic capsule adverse effects,
*Vague or thick surrounding echogenicity – malignancy 1. Deep vein thrombosis 1.6x
• Management: 2. Pulmonary emboli 3.0x
− Excision 3. Endometrial cancer 2.5x
− Cryoablation 4. Cataract surgery 2.0x
• Differential diagnoses: − Raloxifene: less adverse effects
− Benign adenoma: sparse stroma • Genetic testing for BRCA mutations, if positive:
(1) Tubular adenoma – young, non-pregnant 1. Prophylactic mastectomy and reconstruction
(2) Lactating adenoma – pregnancy, post-partum 2. Prophylactic oophorectomy and HRT
− Hamartoma: discrete 2 – 4 cm, firm, sharply circumscribed 3. Intensive surveillance for breast and ovarian cancer
− Adenolipoma: sharply circumscribed nodules of fatty tissue 4. Chemoprevntion
with normal lobules and ducts
3. Phylloides Tumor NATURAL HISTORY
• Rapidly growing giant fibroadenomas that are rarely malignant • Untreated patients:
• Rarely metastasizes to axillary lymph nodes − 5 year survival rate: 18%
• Treatment: − 10 year survival rate: 3.6%
− Wide local excision: with normal rim of tissue while small • Most common cause of death – metastatic disease
− Mastectomy: if size is too big • Most common age group affected: 40 – 60 years old
− If with metastasis à Malignant: Axillary dissection • Most common location – upper outer quadrant
4. Intraductal Papilloma − Greatest breast volume
• Unilateral bloody discharge with solitary involvement of duct
• Usually nonpalpable PRIMARY BREAST CANCER
• If mass is present consider malignancy • Presentation
• Treatment: Central duct excision − Breast enlargement or asymmetry
5. Mammary Duct Ectasia − Skin retraction: due to desmoplastic response entrapping and
• Palpable retroareolar mass with nipple discharge or retraction shortening Cooper’s suspensory ligaments in response to cancer
• Common in older women growth and invaions
• Dilatation of subareolar ducts can occur − Peau d’orange (localized edema) with drainage of lymph from
• Treatment: Excision disrupted skin
6. Physiologic Gynecomastia − Ulceration or erythema of the skin of the breast
• Occurs during neonatal, adolescent, senescent periods − Small satellite nodules near primary ulceration
• Causes: − Musculoskeletal discomfort
− Estrogen excess − No breast pain
− Androgen deficiency *Breast pain is associated with benign disease
− Drug-related
− Systemic diseases AXILLARY LYMPH NODE METASTASES
• Most important prognostic correlate of disease-free and overall survival
MANAGEMENT OF CYSTS • Sequential spread from low (level I) to central (level II) to apical (level
• Imaging prior to needle biopsy is preferred, but often the initial test for III) lymph node groups
palpable breast masses is needle biops • Involved LNs are initially ill-defined and soft but become firm or hard
• Two cardinal rules of safe cyst aspiration: and eventually adhere to each other to form a conglomerate mass
1. Mass must disappear completely after aspiration
2. Fluid must not be bloodstained DISTANT METASTASES
• If residual mass exists à ultrasound examination • Most common cause of death in breast cancer patients 10 years after
− Exclude persistent cyst à re-aspirate initial treatment
• If mass is solid à obtain tissue specimen • At the 20th cell doubling or when the primary cancer exceeds 0.5 cm in
• If cystic fluid is bloodstained à 2 mL taken for cytologic exam diameter, the mass acquires its own blood supply (neovascularization);
− Followed by ultrasound thus able to shed cancer cells directly into systemic venous blood:
− Followed by needle biopsy of any solid area on the wall − Axillary and intercostal veins à pulmonary circulation
• Pneumocystography – inject air into cyst then obtain a repeat − Batson’s plexus à vertebral column
mammogram to allow better assessment of cyst cavity for any • Sites of distant metastases:
irregularities − Bone: most common
− Lung
MALIGNANT LESIONS OF THE BREAST − Pleura
Factors for developing Breast Cancer: − Soft tissue
PROTECTIVE FACTORS RISK FACTORS − Liver
Low estrogen states High estrogen states
Late menarche Early menarche THEORIES ON BREAST CANCER SPREAD
Multigravida Nulligravida
1. Halsted Model – breast CA spread follows a course, proven false
Early menopause Late menopause (> 45 y/o)
Early full term pregnancy Older age at 1st live birth (> 35 y/o) 2. Fisher Model – breast CA can spread anywhere because from the
(18 – 25 y/o) Obesity (Peripheral estrogen) beginning it is a systemic disease, currently accepted model
Breast feeding (Prolactin) Hormone replacement therapy
Moderate exercise Oral contraceptives
OTHER RISK FACTORS
Family history of breast CA
Genetic anomalies: BRCA1 (ovarian and breast CA) and 2
(breast CA), Autosomal dominant inheritance
Radiation exposure
Alcohol (estradiol)
High fat diet
*Women who possess no identifiable risk factors account for 85 – 90%
Life is what you make it. Vita qua se facies est! 6
HISTOPATHOLOGY pN0(mol-)
No regional lymph node metastasis histologically, negative molecular
Non-infiltrating (in-situ) Carcinoma findings (reverse transcriptase polymerase chain reaction RT-PCR)
CRITERIA DUCTAL CIS LOBULAR CIS No regional lymph node metastasis histologically, positive molecular
pN0(mol+)
90% are premenopausal findings (RT-PCR)
> 50% are post menopausal pN1mi Micrometastasis (> 0.2 mm, none > 2.0 mm)
Patients Observed only in women
(Same as Invasive Ductal CA) pN1a Metastasis to 1 to 3 axillary lymph nodes
90% are ER (+)
25 – 35% risk for invasive Metastasis in internal mammary nodes with microscopic disease detected
25 – 70% risk for invasive ductal or pN1b
Malignant ductal or lobular CA in 15 by sentinel lymph node dissection, not clnically apparent
lobular CA in 5 years, usually Metastasis in 1 to 3 axillary lymph nodes and in internal mammary lymph
degeneration years, either breast, any
ipsilateral and in same quadrant pN1c nodes with microscopic disease detected by sentinel lymph node
quadrant
Never palpable dissection but not clinically apparent
Characteristics Palpable mass is rare pN2a Metastasis in 4 to 9 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm)
Multicentric, bilateral
Radiographic Metastasis in clinically apparent internal mammary lymph nodes in the
Microcalcifications Usually none pN2b
findings absence of axillary lymph node metastasis
Total mastectomy vs. Conservative Metastasis in ≥ 10 axillary lymph nodes (at least 1 tumor deposit > 2.0 mm),
Management Observation + Tamoxifen pN3a
surgery or in infraclavicular lymph nodes
Infiltrating Malignancies Metastasis n clinically apparent ipsilateral internal mammary lymph nodes
in the presence of 1 or more positive axillary lymph nodes, or in > 3 axillary
1. Paget’s Disease of the Nipples pN3b
lymph nodes with clinically negative microscopic metastasis in internal
• Chronic eczematoid eruption of the nipple mammary lymph nodes
• May progress to ulcerated, weeping lesion pN3c Metastasis in ipsilateral supraclavicular lymph nodes
• Nipple biopsy – pathognomonic: large, pale, M DISTANT METASTASIS
vacuolated cells (Paget cells) in the rete pegs of the epithelium MX Presence of distant metastasis cannot be assessed
• Treatment – lumpectomy, mastectomy, modified radical M0 No distant metastasis
mastectomy M1 Distant metastasis present
2. Infiltrating Ductal Carcinoma with Productive Fibrosis
• Scirrhous or Invasive Ductal CA AJCC STAGE GROUPINGS AND TREATMENT OPTIONS
• Most common form of breast cancer (75 – 80%) STAGE TNM TREATMENT
• Affects 40 – 60 years old age group Lobular Cis – Observation with Tamoxifen, Bilateral
• Presentation mastectomy with reconstruction
0 TisN0M0 Ductal Cis – Total mastectomy (gold standard), Conservative
− Solitary, hard, non-tender, ill-defined mass breast surgery: lumpectomy, quadrantectomy, segmental
− With skin dimpling (due to profound desmoplastic response) mastectomy and irradiation
• Cut surfaces reveals central stellate configuration with chalky I T1N0M0
white or yellow streaks extending to surrounding breast tissues T0N1M0 Breast conservative surgery with separate axillary node
• Variants of Invasive Ductal Carcinoma: IIA T1N1M0 dissection and irradiation
(1) Medullary Carcinoma – large, soft, hemorrhagic, bulky T2N0M0 Modified radical mastectomy (Total mastectomy with axillary
T2N1M0 dissection)
mass associated with favorable prognosis IIB
T3N0M0
(2) Tubular Carcinoma – most differentiated variant, small,
T0N2M0
non-palpable, best prognosis, found on screening T1N2M0 Modified radical mastectomy (MRM)
mammography IIIA
T3N1M0 Induction chemotherapy + MRM + Radiation
(3) Mucinous Carcinoma (Colloid CA) – bulky, mucinous T3N2M0
tumor with glistening, glaring, gelatinous cut surface T4N0M0
Induction chemotherapy
(4) Secretory Carcinoma (Juvenile CA) – most common form IIIB T4N1M0
Good response à MRM + Radiation
T4N2M0
in children and adolescents, often mistaken for Poor response à Radiation + MRM
IIIC AnyTN3M0
firboradenoma
Locally Advanced Breast Cancer and Inflammatory Cancer
3. Papillary Carcinoma – lowest frequency of axillary nodal involvement Palliation
with good survival rate IV AnyTAnyNM1 Radiation and/or palliative hygienic mastectomy and/or
4. Lobular Carcinoma – from terminal ductures of lobules, often bilateral, chemotherapy and/or hormonal therapy and/or biologic
multicentric, multifocal therapy
5. Inflammatory Carcinoma
• Worst prognosis (T4) MANAGEMENT
• Presentation – erythema, Peau d’ orange, skin ridging LOCAL CONTROL
• Subdermal lymphatics and vascular changes permeated with foci 1. Surgery
of highly undifferentiated tumor • Classical Radical Mastectomy (Halsted, Father of Modern Surgery)
− Removes:
TNM STAGING OF BREAST CANCER (1) Whole breast
T TUMOR (2) Overlying skin
TX Primary tumor cannot be assessed (3) Axillary lymph nodes
T0 No evidence of primary tumor (4) Pectoralis major and minor
Carcinoma in situ; Intraductal CA, Lobular CA in situ; Paget’s Disease of the • Modified Radical Mastectomy ( Patsy & Madded)
Tis
Nipple
− Total mastectomy + Axillary lymph node dissection
T1 Tumor ≤ 2.0 cm in greatest dimension
T2 2.0 cm < Tumor < 5.0 cm in greatest dimension
− Most common operation performed for breast cancer in the
T3 Tumor ≥ 5.0 cm in greatest dimension Philippines
T4 Tumor of any size with direct extension to: (1) Chest wall or (2) Skin, • Conservative Breast Surgery (Veronesi & Fischer)
T4a Extension to chest wall − Quadrantectomy/lumpectomy
Edema (including Peau d’ orange) or skin ulceration or satellite skin nodules − Axillary sampling
T4b
confined to the same breast − Radiation of breast (because breast CA is multicentric)
T4c Both of above − Most common procedure done in the USA
T4d Inflammatory carcinoma − Increased recurrent risk compared to MRM
N REGIONAL LYMPH NODES – CLINICAL − Contraindications:
NX Regional lymph nodes cannot be assessed
(1) Tumor > 5 cm
N0 No regional lymph node metastasis
N1 Metastasis to movable ipsilateral axillary lymph node
(2) Poorly defined tumor
Metastasis in ipsilateral axillary lymph node fixed to one another (matted) (3) Large tumor in a small breast
N2a (4) Pregnancy
or to other structures
Metastasis only in clinically apparent ipsilateral internal mammary nodes in (5) Previous irradiation in the same site
N2b
the absence of clinically evident axillary lymph node metastasis (6) Multiple tumors within the breast confirmed to be
N3a Metastasis in ipsilateral intraclavicular lymph nodes malignant
Metastasis in ipsilateral internal mammary lymph nodes and axillary lymph (7) Diffuse microcalcifications on mammography
N3b
nodes
(8) Tumor involves skin or chest wall
N3c Metastasis to ipsilateral supraclavicular lymph nodes
(9) Presence of vascular collagen disorders (e.g.
pN REGIONAL LYMPH NODES – PATHOLOGIC
Regional lymph nodes cannot be assessed (previously removed, or not
Scleroderma) resulting to poor radiation assimilation
pNX
removed for pathologic study)
pN0(i-) No regional lymph node metastasis histologically, negative IHC results
No regional lymph node metastasis histologically, positive IHC results, no
pN0(i+)
IHC cluster > 0.2 mm
Life is what you make it. Vita qua se facies est! 7
2. Radiation GALLSTONE DISEASE S
• Indications: RECALL: ANATOMY AND PHYSIOLOGY OF THE BILIARY TREE
− Tumor size > 5 cm
− Multiple (≥ 4) involved axillary nodes GALLBLADDER – concentrates and stores hepatic bile, and delivers bile into
− Extracapsular extension of nodal tumor duodenum in response to a meal
− Locally advanced breast cancer a. Right hepatic duct
− Skin involvement b. Left hepatic duct
c. Common hepatic duct
SYSTEMIC CONTROL d. Portal vein
1. Chemotherapy e. Hepatic artery
• Adjuvant chemotherapy – given before initiation of local therapy f. Gastroduodenal artery
• Advantages: g. Left gastric artery
− Reduction of initial tumor burden before surgery h. Common bile duct
− Ability to treat potential systemic disease without delay i. Fundus of the gallbladder
− Ability to assess response of tumor to treatment rendered j. Body of the gallbladder
• Standard treatment – 4 cycles Doxorubicin + 4 cycles Taxane k. Infundibulum
• Response: l. Cystic duct
− Complete response: tumor disappeared m. Cystic artery
− Partial: > 50% tumor burden disappeared n. Superior pancreaticoduodenal
− Non-response: proceed to Cobalt therapy artery
− Progression: worsens after therapy
2. Hormonal therapy
• Ideal when patient is ER (+) and PR (+) • Shape – small avocado fruit hanging from a branch (cystic duct=stem)
− ER (+), PR (+): Diploid, well-differentiated = 80% response • Size – 7 to 10 cm long and 3 to 5 cm wide
− ER (+), PR (-): Aneuploid, not differentiated = 10% response • Peritoneum – visceral peritoneum of the liver attaches its fossa to inferior
− ER (-), PR (+): 45% response surface of the liver
− ER (-), PR (-): Progressive, bad prognosis • Parts
• Anti-estrogen agents: (1) Fundus
(1) Tamoxifen 20 mg daily for 5 years − Inferior blind end normally extending 1 to 2 cm beyond the
− Most common form of hormone therapy liver’s margin (at the inferior border of the liver)
− Blocks ER sites preventing estrogen effects − Mayo-Robson’s point – at the level of the tip of the 9th cc,
− For pre/post menopausal patients with T > 1 cm, (+) intersecting the linea semilunaris, at the transpyloric line of
axillary lymph nodes, ER/PR (+) Addison
− Adverse effects (< 5%) − Contains smooth muscles of the organ
o Endometrial cancer (2) Body (Corpus)
o Thromboembolic events − Average capacity of 30 to 50 ml
(2) Aromatase Inhibitors: Letrozole, Anastrazole, Exemestane − When distended, can distend and contain up to 300 ml
− Blocks conversion of steroids to estrogen − Main storage area and contains most of elastic tissue
− For post menopausal women and estrogen rich tumors − Underneath the liver, directed supero-medially tapering to
− Adverse effects: the porta hepatis
o Bone fractures (3) Neck – funnel shaped, angles down, continues as cystic duct
o Muscle and joint pains (4) Hartmann’s pouch (Infundibulum) – distended neck or upper body,
o Cardiovascular side effects lies in the deepest part of the gallbladder fossa
(3) Others: Diethylstilbestrol, Aminogluthatimide (5) Spiral valve of Heister – spiral mucus folds regulating flow of bile at
3. Biological therapy the neck and cystic duct with great concentration of smooth
• Human Epidermal Growth Factor Receptor 2 (HER2 gene) muscles
− Helps control how cells grow, divide, and repair themselves • Neurovascular supply
− HER2 (+) tumors are aneuploids, grow fast, and are − Cystic artery from the Hepatic artery
aggressive (poor prognosis) but respond well to HER2 *Landmarks: Triangle of Calot
antibody therapy Superior border – Inferior surface of the liver
− Fluorescence in situ hybridization (FISH test): amplified when Right border – Cystic duct
HER2 is positive Medial border – Common Hepatic duct
− Transtuzumab (Herceptin): − Cystic vein which drains to the Portal vein
o Recombinant humanized monoclonal antibody against − Celiac plexus formed by sympathetic and parasympathetic
the extracellular domain of HER2 NEU or ERB-2 vagal fibers
o Reduces risk of recurrence by 50% and death by 33%
• Bevacizumab BILIARY TREE *By order of bile flow:
− Humanized monoclonal antibody against Vascular a. Bile canaliculi
Endothelial Growth Factor Receptor (VEGF) b. Bile ductules
c. Bile ducts
FOLLOW-UP AND PROGNOSIS d. Hepatic ducts
• 80% recurrence within the first 5 years e. Common hepatic duct
• 65 – 85% of recurrences detected by history and PE f. Cystic duct
• Improved survival among patients who later become pregnant g. Common bile duct
• Metastatic disease generally cannot be cured, median survival of 2 Joined by the:
years h. Main pancreatic duct of
Wirsung
REFERENCES: • The Common bile duct and
1. Benign Disorders of the Breast by Fernando L. Lopez, MD, FPCS, FPSGS, Main pancreatic duct
FACS, Professor, Department of Surgery Faculty of Medicine and penetrate the poster-medial
Surgery University of Santo Tomas border of the wall of the 2nd
2. Malignant Disorders of the Breast by Rey B. Malilay, MD, FPCS, FPSGS, part of the duodenum to
FACS, Professor, Department of Surgery Faculty of Medicine and open in the Greater duodenal
Surgery University of Santo Tomas papilla
3. Brunicardi, C.F., et al. (2010). Schwartz’s Principles of Surgery, 19th ed. • Ampulla of Vater or hepato-
McGraw-Hill Companies Inc.: New York. pancreatico ampulla –
4. D’Orsi CJ, Mendelson, EB, Ikeda, DM, et al. (2003). Breast Imaging dilatation at the terminal part
Reporting and Data System. American College of Radiology. of the joined common bile
5. James, W.D., et al. (2006). Andrew’s Diseases of the Skin: Clinical and Main pancreatic duct
Dermatology, 10th ed. Saunders Elsevier Inc.: Canada. o. Sphincter of Oddi – muscle fibers
6. Jarrell, B.E., et al. (2008). National Medical Series for Independent Study: surrounding the Ampulla of
Surgery, 5th ed. Lippincott Williams & Wilkins: Baltimore. Vater
Life is what you make it. Vita qua se facies est! 8
COMMON BILE DUCT • Integral in differential diagnosis of obstructive jaundice
• Length – 6 to 15 cm • Spiral CT scan gives additional information for staging: vascular
• Position involvement
− At the right side of the hepatic artery 5. Percutaneous Transhepatic Cholangiography
− In front of the portal vein • Able to assess intrahepatic bile ducts
• Location – within the hepato-duodenal ligament • Little role in uncomplicated gallstone disease
• Parts: • Useful in patients with bile duct strictures and tumors
(1) Supraduodenal • A small needle is passed under fluoroscopic guidance into the bile
(2) Retroduodenal duct à Guidewire is passed à Catheter is passed over the wire à
(3) Infraduodenal Cholangiogram and therapeutic interventions (e.g. Biliary drain
(4) Intrapancreatic insertion, Stent placement)
− At the head of the pancreas
− Surrounded by Sphincter choledochus of Boyden –
constricting muscle fibers
− Joins the Main pancreatic duct of Wirsung

BILE FORMATION AND COMPOSITION

• Liver – produces 500 to 1000 mL of bile continuously and excretes it into
bile canaliculi daily
− Increased by:
1. Vagal stimulation
2. Secretin from duodenum released in response to:
a. Hydrochloric acid
b. Partly digested proteins
c. Fatty acids
− Decreased by splanchnic nerve stimulation
• Bile composition:
− Usually alkaline or neutral pH but high protein meal shifts to acidic
− Water and electrolytes: Na, K, Ca, Cl • Complications:
− Proteins − Bleeding
− Lipids: cholesterol and phospholipids − Cholangitis
− Bile pigments: bilirubin diglucuronide – metabolic breakdown − Bile leak
product of hemoglobin converted into urobilinogen by bacteria in − Other catheter related problems
the intestine 6. Magnetic Resonance Imaging
− Bile salts: Cholate and Chenodeoxycholate • Anatomic evaluation of the liver, gallbladder, pancreas
1. Synthesized in liver from cholesterol where they are • Can generate high resolution images of biliary tree and
conjugated with taurine and glycine pancreatic duct (T2, pulse sequences w/ or w/o contrast)
2. Act in bile as anions balanced by Na • MRI with Magnetic Resonance Cholangiopancreatography –
3. 80% of conjugated bile acids absorbed in terminal ileum single noninvasive test for diagnosis of biliary tract and pancreatic
4. Deconjugated by gut bacteria à Deoxycholate and disease
Lithocholate • Sensitivity of 95% and specificity 89% for choledocholithiasis
5. Absorbed by colon 7. Endoscopic Retrograde Cholangiography
6. Enterohepatic circulation (95%) – transported back to liver ADVANTAGES DISADVANTAGES
via portal venous system Allows direct visualization of Complications in 5% of patients:
7. Conjugated and secreted into bile stomach, duodenum, ampulla of Pancreatitis
8. 5% excreted in stool Vater, pancreatic duct, common Cholangitis
• Secretion from gallbladder stimulated by CCK bile duct
Direct access to distal common
DIAGNOSTIC STUDIES bile duct
1. Laboratory studies Diagnostic and therapeutic
• CBC – leukocytosis in cholecystitis Success rate > 90%
• Liver functions tests • Diagnostic and therapeutic intervention of choice for gallstones in
− Elevated bilirubin the common bile duct associated with obstructive jaundice,
− Elevated alkaline phosphatase cholangitis, or gallstone pancreatitis
− Normal to elevated aminotransferases • Side viewing endoscope is placed in the duodenum à Passed
2. Ultrasonography retrograde into the common bile duct for cannulation and
• Initial investigation of any patient suspected of biliary tree disease cholangiogram à (+) Gallstones à Sphincterotomy and stone
ADVANTAGES DISADVANTAGES extraction
Noninvasive, painless, no Operator dependent • Requires IV sedation
radiation Dynamic (static images do not • Endoscopic Retrograde Cholangiopancreatography
Can be performed on critically ill give same information) − Provides direct visualization of biliary and pancreatic ducts
Can examine adjacent organs at Difficult to perform on patients − Therapeutic applications: biliary stone lithotripsy and
the same time with ascietes, distended bowel, extraction in high risk patients
obesity − Complications: bile duct perforation, minor bleeding from
3. Hepatobiliary Radionuclide Scanning (HIDA Scan) sphincterotomy or lithotripsy, cholangitis
• Noninvasive anatomic and functional evaluation of the liver, bile 8. Endoscopic Ultrasound
ducts, and duodenum • Noninvasive imaging of bile ducts and adjacent structures
• Primarily used in diagnosing Acute cholecystitis • Uses a special endoscope with an ultrasound transducer at the tip
• Also useful in choledochal cyst, bile leak, CBD obstruction • Useful for evaluation of tumors and resectability
• Mechanism – 99mT labeled derivatives of Dimethyl Imminodiacetic − Also has a biopsy channel allowing needle biopsy
Acid (HIDA) injected via IV à cleared by liver Kuppfer cells à • Useful for identifying bile duct stones but less sensitive than ERC
excreted in bile
− Liver uptake within 10 minutes
− Gallbladder, bile ducts, duodenum visualized within 60
minutes in fasting subjects
4. Computed Tomography
• Inferior to ultrasonography in diagnosing gallstones
• Primary use is to define the course and status of the extrahepatic
biliary tree and adjacent structures
• Test of choice in patients with suspected malignancy of GB,
extrahepatic biliary system, or nearby organs such as the head of
the pancreas
Life is what you make it. Vita qua se facies est! 9
GALLSTONE DISEASE
• Prevalence: 11 – 36%
• Risk factors:
1. Obesity
2. Pregnancy
3. Dietary factors
4. Crohn’s disease
5. Terminal ileal resection
6. Gastric surgery
7. Hereditary spherocytosis
8. Sickle cell disease
9. Thalassemia
• Women are 3 times more likely to develop gallstones
• First degree relatives of patients with gallstones have 2 fold greater risk
NATURAL HISTORY
• Most remain asymptomatic throughout life (Incidental finding)
• But 3% become symptomatic each year
− Caused by stone obstructing cystic duct
− Recurring bouts of biliary colic
− 3 to 5% develop complicated gallstone disease each year
• Indications for prophylactic cholecystectomy
− Absolute indication: Porcelain gallbladder – rare premalignant
condition where the wall of the gallbladder becomes calcified
− Elderly with diabetes
− Individual isolated from medical care for extended periods of time
− Populations with increased risk of gallbladder cancer
GALLSTONE FORMATION – result of solids settling out of solution
1. CHOLESTEROL STONES – > 70% cholesterol by weight
• Form in gallbladder
• Supersaturation of bile with cholesterol due to hypersecretion
− Highly non-polar, insoluble in water and bile
− Cholesterol-phospholipid vesicles (Carry majority of
cholesterol) + Micelles (Bile salt-phospholipid-cholesterol
complexes)
− Vesicular phospholipid incorporated in Micelles
− Vesicular cholesterol stays, crystallizes
• Pure cholesterol stones are uncommon (<10%)
− Variable amounts of bile pigments, calcium
• Presentation:
− Multiple large stones with smooth surface
− May be hard, faceted or irregular, mulberry-shaped, soft
− Yellow to green to black
• Radiolucent (< 10% radiopaque)
• Management – Philippine National Cooperative Gallstone Study:
Chenodeoxycholic acid over 2 year period
− Complete resolution in 13%
− Partial dissolution in 41%
− Recurrence: 50% in 5 years
2. PIGMENT STONES – < 20% cholesterol + Calcium bilirubinate
• BLACK PIGMENT STONES
− Form in gallbladder
− Hemolytic disorders (hereditary spherocytosis, sickle cell
disease, cirrhosis) à Increased conjugated bilirubin à
Increased unconjugated bilirubin à Supersaturation of bile
with calcium bilirubinate, carbonate, and phosphate
− Small, brittle, black, spiculated
− Common in Asian countries
• BROWN PIGMENT STONES
− Form in gallbladder or bile ducts
− Bile stasis à Bacterial infection (e.g. Escherichia coli): β-
glucoronidase à Cleaves bilirubin glucuronide à Insoluble
unconjugated bilirubin à Precipitated calcium bilirubinate +
Dead bacterial cell bodies
− < 1 cm brown-yellow, soft, mushy
− In Asians: parasite infection
− In Caucasians: biliary strictures or common bile duct stones
SYMPTOMATIC GALLSTONES
1. CHRONIC CHOLECYSTITIS (BILIARY COLIC)
• 2/3 of patients with gallstone disease
• Due to obstructed cystic duct à progressive increase of tension in
the gallbladder wall
• Possible pathologic changes (do not correlate with symptoms)
− None (normal gallbladder)
− Minor mucosal inflammation (hypertrophied mucosa)
− Shrunken non-functioning gallbladder with gross transmural
fibrosis and adhesions to nearby structures (atrophied
mucosa) à epithelium protrudes into muscle coat à
formation of Aschoff-Rokitansky sinuses
• Clinical presentation
− Biliary colic:
(1) Abrupt, severe episodic
(2) Increasing in severity
(3) Epigastric or RUQ
(4) Radiates to right upper back or between scapulae
(5) Occurs at night or after a fatty meal
(6) Associated with nausea and vomiting
− Atypical presentation:
(1) Back, LUQ, RLQ pain
(2) Bloating, belching
*r/o PUD, GERD, hernias, IBS, diverticular disease, liver disease,
renal calculi, pleuritic pain, MI
− Physical exam: RUQ tenderness during attacks
2. ACUTE CHOLECYSTITIS
• Secondary to gallstones in 90 – 95% of cases
• Impacted stone in the cystic duct resulting to pain > 24 hours
− Pain does not subside, unremitting, persists for several days
− RUQ or epigastrium, may radiate to right upper back or
interscapular area
• Accompanying symptoms:
− Fever
− Anorexia
− Nausea and vomiting
− Reluctant to move (parietal peritoneum affected)
• Physical exam:
− Focal tenderness, guarding in RUQ
− Palpable mass (gallbladder + adherent omentum)
− Murphy’s sign: inspiratory arrest with deep palpation in right
subcostal area
− Severe jaundice: suggestive of,
(1) Common bile duct stones
(2) Obstruction of bile ducts by severe pericholecystic
inflammation secondary to impaction of a stone in the
infundibulum of GB that mechanically obstructs bile
duct (Mirizzi’s syndrome)
• Pathogenesis – Gallstone obstructs cystic duct à GB distention,
inflammation (mediated by lysolecithin, bile salts, platelet
activating factor, prostaglandins), and edema of GB wall à GB
wall becomes thickened grossly and reddish with subserosal
hemorrhages à Pericholecystic fluid accumulates
− Possible outcomes:
(1) Gallstone dislodges in most cases, then inflammation
spontaneously resolves
(2) 5 – 10%: inflammation progresses leading to GB wall
ischemia and necrosis
− Secondary bacterial contamination seen in 15 – 30% à
Acute Gangrenous Cholecystitis à Abscess or empyema
forms in GB à Perforation of ischemic areas
(1) Usually contained by omentum and adjacent organs in
subhepatic space
(2) If free perforation à peritonitis, intrahepatic abscesses,
perforation into duodenum or colon à
Cholecystoenteric fistula
*“Emphysematous Gallbladder” – gas-forming organisms are
part of secondary bacterial infection; gas seen on
abdominal radiographs and CT-scans
• Laboratories:
− Mild to moderate leukocytosis (12 – 15), may be normal
− Leukocytosis > 20 = complicated cholecystitis, e.g.
gangrenous cholecystitis, perforation, cholangitis
− Mild elevation of bilirubin (4)
− Mild elevation of alkaline phosphatase, transaminases,
amylase
• Differential diagnosis:
− Hydrops of the Gallbladder
o Impacted stone without cholecystitis
o Bile is absorbed but mucus is secreted continuously
such that the gallbladder becomes distended with
mucinous material
o S/S: (+) Palpable non-tender gallbladder
o Tx: Early cholecystectomy (avoid complications)
− Others:
(1) Peptic ulcer with or without perforation
(2) Pancreatitis
(3) Appendicitis
(4) Hepatitis
(5) Perihepatitis (Fitz-Hugh-Curtis Syndrome)
(6) Myocardial ischemia
(7) Pneumonia
(8) Pleuritis
(9) Herpes Zoster involving intercostal nerve
Life is what you make it. Vita qua se facies est! 10
DIAGNOSIS OF SYMPTOMATIC GALLSTONES Laparoscopic Cholecystectomy
CHOLELITHIASIS ACUTE CHOLECYSTITIS
CHRONIC 1. 10-mm and 5-mm ports placed through abdominal wall
CHOLECYSTITIS 2. Peritoneal cavity filled with CO2
Ultrasound Sn & Sp > 90% Sn & Sp > 95% Thickened GB 3. Laparoscope with video camera and long instruments used
Hyperdense Thickened GB wall wall
4. Cystic duct and artery clipped and divided
Posterior acoustic Layer of edema within GB Contracted
shadow wall or between GB and GB 5. GB removed starting from the bottom
Move with change in liver (pericholecystic fluid) • Advantages:
position Sonographic Murphy’s − Cosmetic
Other findings: Sign – focal tenderness − Shorter hospital stay
Bile sludge over GB when − Rapid return to activity
Cholesterolosis: compressed by probe
accumulation of
• Relative contraindications
cholesterol in − Coagulopathy
macrophages in GB − Cirrhosis, portal hypertension
mucosa − Pregnancy
Adenomyomatosis/Chole − Generalized peritonitis
cystitis glandularis − Prior surgery (adhesions)
proliferans: hypertrophic
− Severe cardiopulmonary disease
smooth muscle bundles
and epithelial sinus − Hypotension secondary to hypovolemia
formation
HIDA Scan Sn & Sp > 95% Cholecystostomy – alternative when extensive inflammation makes
Nonvisualized gallbladder cholecystectomy too dangerous or patient is too ill
after 4 hours with prompt 1. Gallbladder fundus opened
filling of CBD and
2. Bile and stones removed
duodenum
Cystic duct obstruction 3. Tube placed in gallbladder for external drainage
Increase false positive
result in GB stasis as in References
critically ill patients, or • Evidence based clinical practice guidelines on the diagnosis and
those receiving treatment of cholecystitis by Domingo S. Bongala, Jr., MD, FPCS, Rey
parenteral nutrition
Melchor F. Santos, MD, FPCS, Mario M. Panaligan, MD, FPSMID, Nilo C.
ERC/ERCP Direct visualization of
ampullary region
de los Santos, MD, FPCS, Maita Rigor, MD, FPCS, Michael Brillantes, MD,
Direct access to distal FPCS, Antonio L. Anastacio, MD, FPCS for the Philippine College of
common bile duct Surgeons, 2003
Diagnostic and • Brunicardi, C.F., et al. (2010). Schwartz’s Principles of Surgery, 19th ed.
therapeutic McGraw-Hill Companies Inc.: New York.
(Sphincterotomy and • Jarrell, B.E., et al. (2008). National Medical Series for Independent Study:
extraction)
Success rate > 90%
Surgery, 5th ed. Lippincott Williams & Wilkins: Baltimore.
Endoscopic Useful in identifying bile
Ultrasound duct stones
Less sensitive than ERC
but less invasive

MANAGEMENT

Empiric Antibiotic Therapy for Acute Cholecystitis

• Should cover gram-negative aerobes and anaerobes
• Typical regimen – 2nd or 3rd generation cephalosporin + Metronidazole
• B-lactam allergy – Aminoglycoside + Metronidazole

Philippine College of Surgeons, 2003

UNCOMPLICATED COMPLICATED
First line Cefazolin 1g IV q8h Cefoxitin 2g IV q8h
Cefuroxime 1.5 g IV q8h Ertapenem 1g IV q24h
Cefoxitin 2 g IV q8h (if at risk for Ampicillin-sulbactam 1.5 – 3g IV q6h
anaerobic infection) (Add Gentamicin 240 mg IV q24h if
with risk for enterococcal infection)
B-lactam Fluoroquinolone 400 mg IV Fluoroquinolone 400 mg IV q12h +/-
allergy q12h +/- Metronidazole 500 mg Metronidazole 500 mg IV q6h
IV q6h
Discontinue Absence of fever for 24 hours (T < 38°C)
Normal WBC count with 3% or less band forms
Ability to tolerate oral intake

Cholecystectomy
ACUTE CHRONIC
CHOLELITHIASIS
CHOLECYSTITIS CHOLECYSTITIS
Cholecystectomy Routine procedure NOT Definitive Laparoscopic –
recommended Advised within 72 procedure of
May be considered in hours of admission choice
select patients: high risk, Laparoscopic –
areas with high procedure of
incidence of choice
gallbladder cancer,
porcelain gallbladder In surgically unfit:
(risk of malignancy) Antibiotics +
Laparoscopic 6
weeks to 2 months
later
Or Percutaneous
Cholecystostomy

Open Cholecystectomy
1. Right subcostal incision
2. GB moved off liver, usually starting at the top
3. Cystic duct and artery ligated and divided during the course of the
operation

Life is what you make it. Vita qua se facies est! 11

HERNIA • Contents of the inguinal canal:
Recall: Anatomy of the Groin 1. Genital branch of the Genitofemoral nerve
2. Ilio-inguinal nerve (part of Lumbar plexus) passes through part of
INGUINAL CANAL the canal and exits through the Superficial inguinal ring with the
• Slit-like passage extending in a downward and medial direction, just other contents
above and parallel to the lower half of the inguinal ligament 3. Spermatic cord in men, which includes:
• Inguinal (Poupart’s) ligament – comprised of interior fibers of the (1) Ductus deferens
external oblique aponeurosis, from the ASIS to the pubic tubercle (2) Artery to Ductus deferens
(3) Testicular artery
(4) Pampiniform plexus of veins (Testicular veins)
(5) Cremasteric artery and vein
(6) Genital branch of Genitofemoral nerve
(7) Sympathetic and Visceral afferent nerve fibers
(8) Lymphatics
(9) Remnants of Processus vaginalis
4. Round ligament of the uterus in women

• Begins at the Deep inguinal ring and continues for about 4 cm, ending
at the Superficial inguinal ring
1. Deep (internal) inguinal ring
− Beginning of the inguinal canal
− Beginning of the tubular evagination of the Transversalis
fascia that forms one of the coverings of the spermatic cord
in men (Internal Spermatic Fascia) or round ligament of the
uterus in women HESSELBACH’S TRIANGLE (Rectus abdominis, Inguinal ligament, Inferior epigastric artery)
− Location:
o Midway between ASIS and pubic symphysis CLASSIFICATION SYSTEMS OF HERNIAS – for standardization in comparing
o Just above inguinal ligament outcomes of various hernias (little clinical significance)
o Immediately lateral to the Inferior Epigastric Vessels 1. Gilbert’s classification system– intraop assessment of location and size
2. Superficial (external) inguinal ring Type 1 Small internal ring, indirect
− End of the inguinal canal
Type 2 Medium (moderately dilated internal ring), indirect
− Beginning of the tubular evagination of the Transversalis
Type 3 Large (internal ring > 2 fingerbreadths), indirect
fascia that forms one of the coverings of the spermatic cord
Type 4 Complete disruption of entire inguinal floor, direct
(External Spermatic Fascia)
− Located superior to the pubic tubercle Type 5 With small (< 1 fingerbreadth) diverticular opening, direct
− Triangle-shaped opening in aponeurosis of External oblique Type 6 Combined direct and indirect (Pantaloon)
o Base – pubic crest Type 7 Femoral
o Sides of triangle – medial crus and lateral crus attached 2. Nyhus classification system – location, size of defect + integrity of
to pubic symphysis and pubic tubercle respectively inguinal ring and floor
o Apex – points superolaterally; intercrural fibers hold the Indirect, internal abdominal ring normal,
Type I
two crura together to prevent further widening of ring typical in infants, children, small adults
Indirect, internal ring enlarged w/o impingement on inguinal floor
Type II
Does not extend to scrotum
Type IIIA Direct, size not taken into account
Indirect, large enough to encroach upon posterior inguinal wall
Type IIIB
Usually includes indirect sliding or scrotal hernias, Pantaloon
Type IIIC Femoral hernia
Type IV Recurrent hernia
3. Schumpelick classification system – adds orifice sizing
Type I < 1.5 cm L – Lateral indirect site
Type II 1.5 – 3.0 cm M – Medial direct site
Type III > 3 cm F – Femoral
• Anterior wall
− Formed along its entire length by aponeurosis of External oblique
ETIOLOGY
− Reinforced laterally by medial fibers of Internal oblique which
• Congenital defects
originate from lateral 2/3 of inguinal ligament
• Loss of tissue strength and elasticity due to aging or repetitive stress
o Adds additional covering over Deep inguinal ring: potential
• Trauma (especially operative trauma)
point of weakness
• Increased intra-abdominal pressure due to:
o Contributes Cremasteric fascia containing Creamsteric
− Heavy lifting
muscle to coverings of structures traversing inguinal canal
− Coughing, asthma, COPD
• Posterior wall
− Bladder outlet obstruction (e.g. BPH)
− Formed along its entire length by Transversalis fascia
− Prior pregnancy
− Reinforced along medial 1/3 by the Cojoint tendon (Inguinal falx)
− Ascites and abdominal distention, obesity
− Reinforces Superficial inguinal ring
• Roof (Superior wall)
DESCRIPTIVE TERMINOLOGY
− Formed by arching fibers of Transversus abdominis and Internal
• Reducible – contents can be pushed back into abdomen
oblique passing from lateral points of origin from inguinal ligament
• Incarcerated – cannot be pushed back
to common medial attachment as Cojoint tendon
• Obstructing – contains loops of bowel that is kinked and obstructs GIT
• Floor (Inferior wall)
• Strangulated – contents are ischemic and will necrosedue to
− Formed by medial ½ of Inguinal ligament
compromise of blood supply
− Rolled-under, free margin of lowest part of aponeurosis of external
• Sliding – wall of sac is partly formed by retroperitoneal structure such as
oblique forms gutter on which contents of inguinal canal are
colon or bladder instead of peritoneum
positioned, reinforced by lacunar ligament
• Richter’s hernia – only one side of bowel is trapped in the hernia (usually
antimesenteric side) rather than entire loop, at risk for perforation
Life is what you make it. Vita qua se facies est! 12
INGUINAL HERNIAS PHYSICAL EXAMINATION
• 75 – 85% of hernias occur in the groin (inguinal) area • Always perform same examination on the other side to:
− 8 – 10%: Incisional hernias − Compare affected area vs. contralateral normal area
− 3 – 8%: Umbilical hernias − Investigate whether there is bilateral involvement
• Protrusion or passage of a peritoneal sac with or without abdominal • Examine patient in standing position with groin
contents through a weakened part of the abdominal wall in the groin area fully exposed
• Peritoneal sac enters the inguinal canal either: − Increases intra-abdominal pressure so that
hernia can be more easily elicited
INDIRECT INGUINAL HERNIA DIRECT INGUINAL HERNIA • Inspection:
Enters through posterior wall of − Is the abnormal bulge along the groin? Or
Enters through deep inguinal ring within the scrotum?
inguinal canal
− Is the bulge not obvious?
• Palpation:
− Place index finger into the scrotum, aimed toward external
inguinal ring to palpate inguinal canal
− Ask patient to cough or bear down to protrude hernia contents
(Valsalva’s maneuver)
• Inguinal occlusion test
− Place finger over the internal inguinal ring, ask patient to cough
− Controlled cough impulse felt on tip of finger = Indirect
− Uncontrolled Cough impulse felt on dorsum of finger = Direct
• Femoral hernia – palpable below inguinal ligament

More common in men – possibly because men have larger inguinal canal MANAGEMENT
Bimodal – peaks before 1 year of age and after 40 years of age
90% of inguinal hernia repairs are performed in men
Most common type of inguinal hernia Most common type of inguinal hernia
in women
Pathology – congenital*: partially/ Pathology – acquired: secondary to
completely patent processus either raised intra-abdominal
vaginalis pressure, damage to nerves of
anterior abdominal wall, weakening
of walls of inguinal canal
Sac passes lateral to inferior Sac passes medial to the inferior
epigastric vessels epigastric vessels (usually through
weakened posterior wall of inguinal
canal), in Hesselbach’s triangle
Extent of excursion down canal Does not traverse entire length of
depends on amount of processus inguinal canal but may exit through
vaginalis that remains patent (may superficial inguinal ring Diagnosis
pass through spermatic cord, • For clinically ambiguous cases such as:
scrotum) − Obese patients
*During the third trimester, the testes descend from the intra-abdominal space into the − Hernias not elicited on PE
scrotum accompanied by the processus vaginalis (finger-like projection of peritoneum). − Recurrent inguinal hernias
At the 36th – 40th weeks AOG the processus vaginalis closes and eliminates the peritoneal • Laparoscopic confirmation – gold standard
opening at the internal inguinal ring. Failure of the peritoneum to close results in patent
• Ultrasound
processus vaginalis (PPV) common in preterm babies. But PPV usually closes within the first
few months of life. − Least invasive
− Positive intra-abdominal pressure is used to elicit herniation of
FEMORAL HERNIA abdominal contents
• Pass through femoral canal into the medial aspect of the anterior thigh − (+) Movement of contents used to diagnose hernia
• Femoral canal − Lack of movement may be false negative
− At the medial edge of the femoral sheath which contains the − Normal movement of spermatic cord and posterior abdominal
femoral artery, femoral vein, lymphatics wall against the anterior may be false positive
− The neck is narrow thus prone to trapping bowel within the sac, • MRI
hence irreducible and susceptible to strangulation − Most sensitive
• Usually acquired − Delineate groin anatomy, demonstrate presence of groin hernia,
• More common in women because of wider pelvises rule out differentials that may affect management plans

PANTALOON HERNIA Treatment

• Combination of direct and indirect hernias – hernia sac passes both • Definitive treatment is surgical repair
medially and laterally to the epigastric vessels − Indirect hernia:
1. Return hernia contents into peritoneal cavity
HISTORY 2. Division and/or ligation of base of hernia sac at the level of
• Usually asymptomatic – noted as an abnormal bulge or incidental peritoneal cavity
finding on PE, laparoscopy 3. In adults, tighten internal ring, repair of wall defect
• In symptomatic patients: − Direct hernia: reinforce inguinal canal floor after invaginating
− Frequent presentation is groin pain hernia sac
1. Generalized pressure or heaviness at the end of the day or − Femoral hernia: close defect in femoral sheath by apposing
after prolonged activity posterior reflection of inguinal ligament to Cooper’s ligament
2. Local sharp pain – may be due to nerve impingement (Cooper’s ligament repair) or by plugging space with
3. Referred pain – neurogenic pains referred to the scrotum, polypropylene mesh
testicle, or inner thigh − Types of Inguinal floor repair
OPEN/
− Extrainguinal symptoms: BASSINI MCVAY’S SHOULDICE LICHTENSTEIN
LAPAROSCOPIC
1. Change in bowel habits – may indicate sliding hernia with Transversalis Transversalis Transversalis Mesh sutured Polypropylene
bowel component fascia and fascia and fascia divided to transversalis mesh reinforces
2. Urinary symptoms – may indicate involvement of bladder conjoint conjoint into two fascia and weak
• Usually increase in size and content over time tendon tendon layers, internal conjoint transversalis
• Note whether there is history of reducibility sutured to sutured to oblique and tendon to fascia
− Ability to push contents back into the abdomen reflection of Cooper’s conjoint Poupart’s
inguinal ligament tendon
ligament sutured to
(Poupart’s) Poupart’s

Life is what you make it. Vita qua se facies est! 13

• Conservative management – usually for asymptomatic or minimally PE Nonpalpable Feeling of “bag of Bulge apparent in standing
symptomatic cases with only small risk for incarceration or strangulation testes worms” position resolves in supine
(+) Intra- position
− Recumbent position: aids self-reduction
abdominal Transillumination of the
− Truss or elastic belt or brief: keeps hernia reduced, but may testes scrotum – displays fluid in the
increase risk for incarceration tunica vaginalis
• Emergent management for compromise of intestinal contents *NOTE: bowel may also
*General anesthesia may reduce incarcerated or strangulated hernia, transilluminate, hence hernia
convert to laparotomy or laparoscopy to fully assess bowel viability (+) Silk glove sign – pass
fingers over pubic tubercle
1. Incarcerated hernia – hernia that cannot be reduced due to
to reveal PPV with thickened
large amount of intestinal contents, dense and chronic adhesions cord or hydrocele sac
of contents to the sac, small neck in relation to contents Diagnosis Clinical Clinical diagnosis Clinical diagnosis
− Reduce before performing definitive repair Doppler Ultrasound – in patients
− Perform taxis: ultrasonography – suspected of torsion, tumor,
o Sedate patient and place in Trendelenburg test of choice for trauma, testicular rupture
o Grasp hernia sac with both hands, elongate, milk back inconclusive PE
Veins 3 mm
through hernia defect
diameter
2. Strangulated hernia – an incarcerated hernia whose blood supply Management Hormonal Indications for Adult noncommunicating –
becomes compromised such that contents become ischemic therapy (hCG, surgical repair: aspiration + sclerosing agent
and lose viability gnRH) before 6 Relieve testicular Others: Surgical repair
− Fever, leukocytosis, hemodynamic instability months old discomfort or pain
− Hernial bulge is very tender, warm, erythematous Surgical therapy unresponsive to
between 6 to symptomatic
− Do not perofrm taxis
12 months of treatment
− Stabilize patient hemodynamically before attempting old: orchiopexy Reduce testicular
reduction and repair If bilateral, atrophy (< 20 ml, <
− Assess bowel viability by: consult 4 cm)
o Color endocrinologist Management of
o Temperature or geneticist infertility
o Peristalsis
o Woods fluorescein test
− If there are non-viable segments resection with anastomosis
to restore intestinal continuity prior to repair is ideal
3. Sliding hernia

DIFFERENTIAL DIAGNOSIS OF GROIN HERNIA

CRYPTOR-
VARICOCELE HYDROCELE
CHIDISM
Definition Undescended Dilatation of Fluid collection within the
or pampiniform processus vaginalis that
maldescended venous plexus produces swelling in the
testis within the scrotum inguinal region or scrotum, or
and internal rarely canal of Nuck in
spermatic vein females
Communicating – PPV
extends all the way into the
scrotum such that it is
continuous with tunica
vaginalis surrounding testicle
Noncommunicating – fluid
confined to scrotum w/in
tunica vaginalis due to
obliterated PV, common in
infants, resolves by 1 year
Reactive – due to
inflammatory condition
Patho- Transinguinal Impaired Small patent processus
physiology migration circulation leading vaginalis allows fluid to pass
normally occurs to elevated heat (communicating hydrocele)
at 28 – 40 weeks *More common in
AOG the left due to
Usually (+) angle left testicular
Family Hx vein enters left
Usually renal vein, lack of
abnormality in effective antireflux
gubernaculum valves, increased
which normally renal vein pressure
pulls testis into due to
scrotum compression
between SMA an
aorta (Nutcracker)
History Nonpalpable Usually Intermittent bulge in the
testes in the asymptomatic groin or scrotal enlargement
scrotum Decreased that may reduce at night in
Prematurity testicular function supine position
Prior inguinal (infertility) due to (+) Pain – quickly expanding
surgery interference with hydrocele
testicular Investigate for causes of
thermoregulation Reactive hydrocele: trauma,
(+) Scrotal pain or torsion, infection, obstructed
heaviness lymphatics

 
 
Life is what you make it. Vita qua se facies est! 14
THYROID DISORDERS S THYROID GLAND
Recall: Thyroid Anatomy and Physiology • Normally brown, firm, weighs 20 g, located posterior to strap muscles
• Blood supply:
TRIANGLES OF THE NECK − Superior thyroid artery (from External Carotid Arteries)
The trapezius and sternocleidomastoid muscles divide the neck into the − Inferior thyroid artery (from Thyrocervical Trunk): crosses the
anterior and posterior triangles on each side. Recurrent Laryngeal Nerve
− Thyroidea ima (from the Aorta or Innominate artery)
Borders: • Innervation:
ANTERIOR TRIANGLE POSTERIOR TRIANGLE − Recurrent laryngeal nerve (from the Vagus nerve)
Median vertical line of neck Middle 1/3 of clavicle o Innervates intrinsic muscles of larynx except Cricothyroid
Inferior margin of the mandible Anterior margin of trapezius o Injury results to:
Anterior margin of Posterior margin of − Unilateral: adducted = weak voice, abducted = hoarse
sternocleidomastoid sternocleidomastoid voice and ineffective cough
− Bilateral: airway obstruction (Stridor)
− Superior laryngeal nerve (from the Vagus nerve)
o Innervates Cricothyroid muscle
o Injury results to inability to tense ipsilateral vocal cord =
difficulty hitting high notes, projecting the voice, voice
fatigue
• Lymphatic drainage

ANTERIOR TRIANGLE OF THE NECK

SUBMANDIBULAR SUBMENTAL MUSCULAR CAROTID
Borders Inferior border of Hyoid bone Hyoid bone Superior belly of
mandible Anterior border Superior belly omohyoid
LEVEL LYMPH NODES
Anterior and of digastric of omohyoid Stylohyoid
I Submaxillary nodes ß Rarely a site for metastasis
posterior bellies of Midline Anterior border Posterior belly of
digastric of SCM digastric II Upper jugular nodes
Midline Anterior border III Middle jugular nodes
of SCM IV Lower jugular nodes
Contents Submandibular Lymph nodes Thyroid gland Bifurcation of the Deep lateral nodes
V
gland Tributaries Parathyroid common carotid Transverse cervical chain
Lymph nodes forming glands artery into ECA Superior thyroid nodes
VI
CN XII Anterior Jugular Recurrent and ICA Anterior superficial cervical nodes
Facial artery, vein Vein laryngeal Int. jugular vein • Histology
nerve CN X, XI, XII − Divided into lobules containing 20 to 40 follicles
− Follicles are lined by cuboidal epithelial cells and contain central
store of colloid, responsible for transport of oiodide, organification,
coupling, release
− Parafollicular (C) cells: contain and secrete Calcitonin, found in
the upper poles of the thyroid lobes
• Physiology

IODIDE
à Na/I Symporter in Thyroid
gland basement
membrane
à Pendrin in Thyroid gland
apical surface
à Thyroglobulin
à Thyroid Peroxidase:
Organification – Iodide +
Tyrosyl residues
à Thyroid Peroxidase:
Coupling
à T3, T4
à Exocytosis, Proteolysis
à Release
à Peripheral metabolism

POSTERIOR TRIANGLE
The inferior belly of the Omohyoid further divides the posterior triangle of the
neck into: superiorly, Occipital triangle, and inferiorly, Sublavian triangle
OCCIPITAL SUBCLAVIAN
Contents CN XI Subclavian artery, vein
Cervical sympathetic ganglia Thyrocervical trunk
Splenius capitis Costocervical trunk
Levator scapula Apex of the lung
Scalenus posterior, medius, anterior Brachial plexus

Life is what you make it. Vita qua se facies est! 15

THYROID HORMONES TESTS OF THYROID FUNCTION
L-THYROXINE (T4) TRIIODOTHYRONINE (T3) 1. Thyroid Stimulating Hormone (N.V. = 0.5 – 5 µU/mL)
100% produced in the thyroid gland 80% from peripheral conversion of T4 • Initial test of choice in patients with suspected thyroid disease
7 day half life 1 day half life • Most sensitive test for screening hypothyroidism and
99.98% protein bound 99.7% protein bound hyperthyroidism (including sublicnical cases)
Only the free hormones are active 3x more potent than T4
• Single most useful screening test (assuming absence of pituitary or
*The fraction of unbound T3 is greater than unbound T4 but there is less hypothalamic disease)
unbound T3 in the circulation since it is produced in smaller amounts and • Principle:
cleared more rapidly − TSH antibodies bind to serum TSH
Effects of Thyroid Hormones − Secondary antibody binds to separate epitope on serum TSH
1. Affect fetal brain development and skeletal maturation − = Amount of TSH is proportional to amount of bound
2. Stimulate Na/K-ATPase in various tissues to increase: secondary antibody
• Oxygen consumption • Reflects ability of anterior pituitary to detect free T4
• Basal metabolic rate − Free T4 is inversely proportional to TSH
• Heat production − Small changes in Free T4 = Large changes in TSH
• Maintain normal hypoxic and hypercapnic drive in the respiratory 2. Free T4 (N.V. 12 – 28 pmol/L) and Free T3 (N.V. 3 – 9 pmol/L) – measures
center of the brain biologically active thyroid hormone
3. Increase transcription of Ca-ATPase in the sarcoplasmic reticulum and • Confirms diagnosis and assesses severity of hyperthyroidism
levels of beta-adrenergic receptors and G proteins resulting to positive • For cases of:
inotropic and chronotropic effects on the heart − Early hyperthyroidism
4. Decrease myocardial alpha receptors to amplify catecholamine − Refetoff Syndrome: end organ resistance to T4
actions 3. Total T4 and Total T3 – measures both free and bound thyroid hormone
5. Increase GI motility • Total T4 (N.V. = 55 – 150 nmol/L)
6. Increase bone and protein turnover − Reflects thyroid output
7. Increase speed of muscle contraction and relaxation − Increased in:
8. Metabolic effects – Increase: (1) Hyperthyroidism
• Glycogenolysis (2) Pregnancy
• Hepatic gluconeogenesis (3) Estrogen/progesterone use
• Intestinal glucose absorption (4) Congenital diseases
• Cholesterol synthesis and degradation − Decreased in:
(1) Hypothyroidism
CLINICAL MANIFESTATIONS (2) Anabolic steroid use
Hyperthyroidism (3) Diseases with protein loss (e.g. Nephrotic Syndrome)
SYMPTOMS SIGNS
• Total T3 (N.V. = 1.5 – 3.5 nmol/L)
Hyperactivity, irritability, dysphoria Tachycardia, atrial fibrillation in elderly
Heat intolerance and sweating Tremor − Reflects peripheral metabolism
Palpitations Goiter − Unsuitable for screening
Fatigue and weakness Warm, moist skin − Increased in early hypothyroidism
Weight loss with increased appetite Muscle weakness, proximal myopathy − Measured in hyperthyroid patients with normal T4 levels to
Diarrhea Lid retraction or lag rule out T3 thyrotoxicosis
Polyuria Gynecomastia
Oligomenorrhea
Status T3, T4 levels TSH levels
Loss of libido
Normal Normal Normal
Subclinical hypothyroidism Normal High
Hypothyroidism Overt primary hypothyroidism Low High
SYMPTOMS SIGNS Subclinical hyperthyroidism Normal Low
Tiredness, weakness Dry coarse skin, cool peripheral extremities Overt primary hyperthyroidism High Low
Dry skin, dry brittle hair Myxedema: puffy face, hands, feet
Feeling cold Diffuse alopecia
Hair loss Bradycardia TSH Free T4
Conditions
Difficulty concentrating, poor memory Peripheral edema levels levels
Constipation Delayed tendon reflex relaxation • Secondary or central hypothyroidism
Low
Weight gain with poor appetite Carpal tunnel syndrome • Severe form of “sick euthyroid syndrome”
Dyspnea Serous cavity effusions • T3 thyrotoxicosis
Hoarse voice • Subclinical hyperthyroidism
Normal
Menorrhagia (later oligo or amenorrhea) LOW • Early phase of thyrotoxicosis treatment with anti-thyroid
Paresthesia medications
Impaired hearing • True thyrotoxicosis
Impaired libido and fertility High (Grave’s disease, toxic nodular goiter, exogenous,
ectopic, cross reactivity from B-hcg)
• Secondary or central hypothyroidism
DIAGNOSTIC ALGORITHM
Low • Severe form of “sick euthyroid syndrome”
Normal variant SIGNS & SYMPTOMS Abscess • Anti-T4 antibodies
NORMAL
  Normal •
•
Normal patient
Thyroid hormone intake just prior to test
High
Normal variant TSH determination Abscess • Anti-T4 antibodies

  Low •
•
Primary hypothyroidism
Subclinical hypothyroidism
TSH > 4 μ IU/mL 0.4 > TSH < 4 μ IU/mL TSH < 0.4 μ IU/mL Normal • Early phase of treatment of primary hypothyroidism with
HIGH
levothyroxine
• TSH-producing adenoma causing thyrotoxicosis
PROBABLE EUTHYROID Free T4 levels High
• Generalized resistance to thyroid hormone (genetic) – rare
HYPOTHYROIDISM
4. Thyrotropin Releasing Hormone – evaluates pituitary TSH secretion
• Procedure:
FT4 normal 0.4 > TSH < 4 μ IU/mL FT4 elevated
− Administer 500 µg TRH
− Monitor TSH levels after 30 and 60 minutes
Free T3 levels 0.4 > TSH < 4 μ IU/mL HYPERTHYROID − Normal result: increase at least 6 µU/ml from baseline
5. Thyroid antibodies
• Do not evaluate thyroid function
• Elevation indicates an underlying disorder
FT3 normal 0.4 > TSH < 4 μ IU/mL FT3 elevated − Most common: Autoimmune thyroiditis
− 80% Hashimoto’s Thyroiditis
− Also seen in:
SUBCLINICAL HYPERTHYROID
HYPERTHYROID
(1) Grave’s disease
0.4 > TSH < 4 μ IU/mL (2) Multinodular goiter
(3) Some thyroid neoplasms

Life is what you make it. Vita qua se facies est! 16

6. Serum Thyroglobulin • For evaluation of thyroid nodules:
• Reflects destructive processes of thyroid − Solid or cystic: cyst appears hypoechoic (black) with
• Seen in: posterior acoustic shadow
− Thyroiditis − Size
− Overactive states: − Multicentricity
(1) Grave’s disease • Uses:
(2) Multinodular goiter 1. Defines size, shape, nature and extent of a palpable nodule
• Most useful for monitoring recurrence in differentiated thyroid 2. Clarifies controversies about palpation (but not a substitute)
carcinoma after total thyroidectomy and RAI ablation 3. Detects non-palpable nodules
7. Serum Calcitonin (N.V. 0 – 4 pg/ml) 4. Color flow doppler provides data to static gray-scale image
• Marker for Medullary Thyroid Carcinoma 5. Screening tool for high risk patients
6. Identifies recurrence of tumor/ local metastasis
THYROID IMAGING 7. Facilitates aspiration biopsy
8. Facilitates percutaneous ethanol injection
9. Monitor therapeutic  goals  

MALIGNANT
• Almost all malignant nodules are
hypoechoic but majority of benign
nodules are also hypoechoic
• Microcalcifications may represent
Psammoma bodies but calcifications
can be a consequence of bleeding
BENIGN
• Halo used to be believed to represent
benign nodules but sometimes found
in malignancy
• Sharp borders represent non-invasion
but majority of malignant nodules also
have sharp borders

4. Computed tomography (CT Scan) and Magnetic Resonance Imaging

• Excellent imaging
• For substernal, large, or fixed goiters which cannot be evaluated
by ultrasound
• NOTE:
− Use non-contrast if patient will undergo RAI therapy
− If contrast is necessary delay RAI therapy

HYPERTHYROIDISM
Etiology
Increased hormone synthesis Release of preformed hormone
(Increased RAIU) (Decreased RAIU)
1. Grave’s disease (Diffuse Toxic Goiter) 1. Thyroiditis (early stage)
2. Toxic multinodular goiter 2. Thyrotoxicosis
3. Plummer’s disease (Toxic Adenoma)
4. Drug induced – amiodarone
1. Radionuclide imaging
5. Jod-Basedow Syndrome – iodine
• Measures thyroid uptake 6. Thyroid carcinoma
INCREASED UPTAKE DECREASED UPTAKE 7. Struma ovarii
Conditions with increased new thyroid Painless (De Quervain’s) Thyroiditis 8. Hydatidiform mole
hormone production, where iodine is needed Subacute Thyroiditis 9. TSH secreting pituitary adenoma
more to manufacture new hormones: Jod-Basedown Syndrome (Iodine-
Grave’s disease induced Hyperthyroidism)
Toxic nodular goiter Exogenous intake of thyroid hormone
Differential Diagnoses
Ectopic thyroid Based on Type of Goiter
Falsely decreased uptake: TYPE OF GOITER DIAGNOSIS
Iodine deficiency – a lot of room for Exogenous thyroid hormone Normal thyroid gland Graves’ disease, Painless thyroiditis, Factitious hyperthyroidism
radioactive iodine Anti-thyroid drugs Diffuse, non-tender Graves’ disease, Painless thyroiditis
Iodinated contrasts Single thyroid nodule Thyroid adenoma (Plummer’s)
• Agents: Multiple thyroid nodules Toxic multinodular goiter
(1) Iodine 123 Tender painful goiter Subacute thyroiditis (De Quervain’s)
• Preferred agent for imaging studies – taken up by
thyroid gland but non-destructive Based on Laboratories and Ancillaries
• Low dose and shorter half life (12 – 14 hours)
(2) Iodine 131
• High dose and longer half life (8 – 10 days)
• For patients with differentiated thyroid carcinoma with
metastatic disease
• Destroys thyroid follicles
(3) Technetium Tc 99m pertechnetate
• Taken up by mitochondria
• Trapped but not organified
• Shorter half life, less radiation exposure
• For nodal metastases
• Contraindications: Pregnancy, breastfeeding
2. Thyroid Scan
• Usually done with thyroid uptake using the same radioisotope
• Pictures are taken by a gamma camera
• Reported as films, pictures, or computer printouts
• Imaging for:
(1) Determining size and shape of gland
(2) Distribution of functionality – shows us exactly where in the
thyroid gland are the isotopes most intensely taken up
• Cold nodule: traps less radioactivity, higher risk for
malignancy
• Hot nodule: traps more radioactivity = more active
3. Ultrasound
• Advantages:
− Noninvasive and portable tool
− No radiation exposure
1. Graves disease (Diffuse Toxic Goiter)
Life is what you make it. Vita qua se facies est! 17
 • Autoimmune disease triggered by either of the following: Advantages Disadvantages
− Post-partum states 1. Rapid, complete, permanent 1. Preoperative preparation
− Iodine intake control of toxicity 2. Morbidity:
2. Removal of mass a. Recurrent and/or Superior
− Infections
3. Treatment of choice for huge goiters Laryngeal nerve injury
− Genetic factors: HLA B8, DR3, HLA DQA10501, CTLA1 b. Hypothyroidism
• Stimulate thyrocytes to grow and produce hormones c. Hypoparathyroidism
• Epidemiology: d. Hematoma, seroma
− Most common cause of hyperthyroidism in North America e. Anesthetic and medical
− Common in females 40 – 60 years old complications
f. Thyroid storm
• Triad:
(1) Diffusely enlarged thyroid gland with increase in
vascularity 2. Toxic Multinodular Goiter
(2) Hyperthyroidism • Common in older patients with history of non-toxic multinodular
(3) Exophthalmos goiter wherein enough nodules become autonomous to cause
hyperthyroidism
• Other clinical manifestations:
− Increased adrenergic stimulation • May be precipitated by:
− Opthalmopathy − Iodide containing drugs (e.g. contrast medium)
− GI symptoms − Amiodarone
− Cardiovascular complications: tachycardia, atrial fibrillation, • Clinical manifestations similar to Grave’s disease but without
congestive heart failure extrathyroidal signs and symptoms
− Thyroid acropachy: subperiosteal bone formation and • Diagnosis:
swelling of metacarpals − Suppressed TSH
− Onycholysis: separation of fingernails from beds − Elevated FT4 and FT3
− Pretibial myxedema − Elevated RAIU
− Females: amenorrhea, decreased fertility, miscarriage • Treatment:
− Children: rapid growth, early bone maturation − Surgical resection: Subtotal thyroidectomy using Hartley-
− Young males: gynecomastia Dunhill Procedure
(1) Total lobectomy on one side
• Diagnosis:
− Suppressed TSH (2) Subtotal thyroidectomy on the other side
− Elevated FT4 and FT3 3. Plummer’s disease (Toxic adenoma)
− Elevated RAIU • Single hyperfunctioning nodule
− Solitary nodule usually 3 cm or larger
− Presence of thyroid receptor antibodies
(1) Thyroid stimulating immunoglobulins • More common in younger patients
(2) Thyroid stimulating antibodies • Linked with gene mutations of TSH-R or gsp
• Medical treatment: • Rarely malignant
• Diagnosis:
− Anti-thyroid drugs
o Inhibit organification and coupling of iodotyrosines − Elevated RAIU (“Hot” nodule)
o Euthyroid state achieved in 4 to 6 weeks • Treatment:
(1) Propylthiouracil – decreases peripheral conversion of T4 − Surgery: lobectomy and isthmusectomy
4. Thyroid storm
to T3, preferred in pregnant or breast feeding women
(less transfer via placenta) • Seen in unprepared patients
(2) Methimazole – longer half life, can be dosed once daily, • Sign and symptoms of thyrotoxicosis are magnified
associated with congenital aplasia • Management:
(3) Carbimazole − Prevention: induce euthyroid state
− Beta-blockers: Propanolol (1) Lugol’s solution
o Symptomatic relief of hypermetabolic state (2) Sodium ipodate – decreases iodide uptake and thyroid
o Can also decrease peripheral conversion of T4 to T3 hormone secretion
− Anti-thyroid drugs: PTU can block formation of new thyroid
Advantages Disadvantages hormone and conversion of T4 to T3
1. No morbidity related to surgery 1. High relapse rate − Beta-blockers: reduce symptoms and peripheral conversion
2. Treatment of choice for small goiters 2. Side effects especially in prolonged − Steroids: prevent adrenal exhaustion and block hepatic
and pregnant patients uses: rashes, fever, neuritis, thyroid hormone conversion
agranulocytosis
3. Crosses placenta HYPOTHYROIDISM
4. Hypothyroidism
5. Patient compliance
Etiology
Primary Secondary Tertiary
(Increased TSH) (Decreased TSH)
• Radioactive Iodine Therapy 1. Hashimoto’s thyroiditis 1. Pituitary tumor 1. Hypothalamic
− Emits low dose radiation to destroy thyroid follicles 2. RAI for Grave’s disease 2. Pituitary resection or insufficiency
− Standard dose: 10 mC = 8,500 cGY 3. Post-thyroidectomy ablation 2. Resistance to
4. Excessive iodine thyroid hormone
Advantages Disadvantages 5. Subacute thyroiditis
1. No morbidity related to surgery 1. Cure rate is dose dependent 6. Antithyroid drugs
2. Ease of treatment 2. Hypothyroidism 7. Lithium
3. Highly effective in diffuse goiter 3. Aggravate exophthalmos
4. Treatment of choice for failed 4. Thyrotoxicosis/thyroid storm Differential Diagnosis
surgical management 5. Crosses placenta
6. Infertility in females
7. Increase cancer risk in children
8. Not effective in nodular goiter

• Surgical treatment
− Preoperative preparation: render patient euthyroid
(1) Lugol’s solution
(2) Saturated potassium iodide
− Indications: Total thyroidectomy or Near total thyroidectomy
(1) Coexistent carcinoma
(2) Severe opthalmopathy
(3) Life threatening reactions to medication
(4) Refusal to undergo RAI therapy
− Indication: Subtotal thyroidectomy – all other situations

Life is what you make it. Vita qua se facies est! 18

1. Congenital Hypothyroidism − Stage 2: Euthyroidism
• 1 in 4,000 newborns − Stage 3: Hypothyroidism
• May be transient as in the following cases, − Stage 4: Resolution and euthyroidism
− Mother has TSH-R blocking antibodies • Diagnosis:
− Mother received antithyroid drugs − Low TSH
• Most cases are permanent − Elevated T4 and T3 due to release of preformed TH
• Manifestations in the newborn: − ESR > 100 mm/h
− Majority appear normal at birth − Decreased RAIU
− Prolonged jaundice • Treatment is symptomatic
− Feeding problems − Aspirin or NSAIDs
− Hypotonia − Steroids for severe pain
− Enlarged tongue − Short term TH replacement
− Delayed bone maturation − Thyroidectomy: for prolonged course and unresponsive
− Abdominal distention, umbilical hernia, rectal prolapse b. Painless Thyroiditis
− Congenital malformations, especially cardiac (4x more • Autoimmune origin
common) • May be sporadic or post-partum (6 weeks after delivery)
− Down Syndrome or dwarfism facies • Common in women 30 – 60 years old
• Diagnosis – Neonatal screening programs based on TSH or T4 level • Clinical features:
measurement in heel-prick blood specimens − Normal sized or minimally enlarged, slightly firm,
• Management nontender thyroid gland
− T4 dose: 10 – 15 μg/kg/day with close monitoring of TSH levels • Diagnosis:
− Immediate treatment is necessary because delays can − Decreased TSH
cause permanent neurologic damage − Elevated T4 and T3
2. Hashimoto’s Thyroiditis or Chronic lymphocytic thyroiditis − Normal ESR
• Transformation of thyroid to lymphoid tissue − Decreased RAIU
• Most common form of thyroiditis • Treatment:
• Most common cause of hypothyroidism − Beta-blockers
• Genetic predisposition − Thyroid hormone replacement
• May co-exist with papillary carcinoma − Thyroidectomy, RAI ablation for recurrent disabling
• Common in women 30 – 50 years old episodes
• Clinical features: 5. Riedel’s Thyroiditis or Invasive Fibrous Thyroiditis
− Diffuse and symmetric enlargement of the neck with pain • Replacement of all or part of thyroid parenchyma by fibrous tissue
and tenderness which also invades adjacent tissue
− Initially hyperthyroid and subsequently euthyroid or • Primary autoimmune and fibrotic disorder
hypothyroid • Common in women 30 – 60 years old
• Diagnosis: • Clinical features:
− Elevated TSH − Painless, hard, anterior neck mass
− Thyroid antibodies: anti-thyroid peroxidase, anti-thyroglobulin − Hard, “woody” thyroid gland with fixation to surrounding
autoantibodies structures
• Treatment: − Compression symptoms
− LT4 suppression: diffuse goiter, nodular goiter − Hypothyroidism
− Surgery: pressure symptoms, suspicion of malignancy, − Hypoparathyroidism
cosmetically unacceptable • Diagnosis:
− Thyroid hormone replacement therapy in hypothyroid − Open thyroid biopsy
especially with hyperlipidemia, hypertension, or pregnant • Treatment: Surgery is the mainstay
3. Acute Suppurative Thyroiditis − Decompress trachea by wedge incision
• Infection caused by: − Tissue diagnosis
− Hematogenous or lymphatic spread − Thyroid hormone replacement + Corticosteroids
− Direct spread from persistent pyriform sinus fistulae or
thyroglossal duct cyst Treatment Algorithm for Hypothyroidism
− Penetrating trauma Initial Levothyroxine Dose
− Immunosuppression Adults: 1.7 μ g/kg/day
• 70% caused by Streptococcus or anaerobes Children: 4.0 μ g/kg/day
• More common in children Elderly: < 1.0 μ g/kg/day
• Preceded by upper respiratory tract infection or otitis media
• Clinical features:
− Severe neck pain radiating to the jaws or ear Normal variant Repeat TSH test Abscess
−
−
Fever and chills
Odynophagia
 
TSH > 4 μIU/ml 0.4 > TSH < 4 µIU/ml TSH < 0.4 μIU/ml
− Dysphonia
Symptoms resolved
• Diagnosis:
− Leukocytosis on blood test
− FNAB: test with Gram’s stain, culture, cytology Increase dose by Continue dose, repeat Decrease dose by
− CT scan: help determine extent of infection 25 – 50 μg/day TSH after 12 weeks 25 – 50 μg/day
− Barium swallow: for Pyriform Sinus Fistula
• Treatment:
− Parenteral antibiotics NODULAR NON-TOXIC GOITER
− Drainage of abscesses • Any enlargement of the thyroid gland
− Complete resection of pyriform sinus fistula and area of • TSH stimulation secondary to inadequate thyroid hormone synthesis
termination in the thyroid 1. Familial goiter
4. Subacute thyroiditis − Inherited enzymatic defect
a. Painful thyroiditis or De Quervain’s Granulomatous Thyroiditis − Impaired iodine metabolism
• Viral origin or post-viral inflammatory response − Usually associated with hypothyroidism
• Genetic predisposition: HLA B35 2. Endemic goiter
• Common in women 30 – 40 years old − Iodine deficiency in diet
• Clinical features: − Intake of goitrogens: kelp, cassava, cabbage
− Acute/gradual onset of neck pain radiating to jaw/ear − Common in mountainous regions
− History of preceding upper respiratory tract infection − Treatment: give iodized salt
− Enlarged, tender, and firm thyroid 3. Sporadic goiter: no definite cause
• Stages: • Clinical features:
− Stage 1: Initial hyperthyroidism due to release of − Pressure sensation in the neck
preformed thyroid hormone − Catarrh

Life is what you make it. Vita qua se facies est! 19

 − Compression symptoms • Additional notes for Suppressive Therapy with LT4
− Positive Pemberton’s Sign: − Long term TSH suppression can lead to bone loss and arrhythmia
o Patient elevates the arms causing the goiter to rise into the in elderly patients and menopausal women
thoracic inlet leading to shortness of breath, stridor, or − Should never be fully suppressive – maintain TSH at 0.3 – 3.3 µU/ml
distention of neck veins − Nodule regrowth is observed after cessation of therapy
o Indicates presence of a substernal goiter − If size decreases continue therapy long term
• Diagnosis: − If nodule regrows consider reaspiration and surgical treatment
− Patchy RAIU • Thyroid nodule during pregnancy
− Patient is usually euthyroid: normal TSH, low-normal FT4 − Follow up includes FNA and US
− FNAB if with dominant nodule or if with painful enlarging nodule − If diagnosed as thyroid CA in the first or second trimester, surgery
− CT Scan can help evaluate extent of retrosternal extension and undertaken in second trimester
airway compression − If diagnosed as thyroid CA in the third trimester, surgery
• Indications for surgical resection (Subtotal thyroidectomy + lifelong T4): undertaken postpartum
1. Large goiter which is cosmetically unacceptable
2. Substernal extension MALIGNANT THYROID DISORDERS
3. Compression symptoms • Most rapidly increasing cancer in women
4. Suspicion of malignancy • RET proto-oncogene – leads to aberrant MAPK activation and
5. Continue to increase in size despite T4 suppression therapy consequent tumorigenesis

DOMINANT or SOLITARY THYROID NODULE WELL DIFFERENTIATED

• Most are benign – Colloid goiter or Adenoma (80 – 90%) 1. Papillary Carcinoma – better prognosis
• Factors suggesting increased risk of malignant potential • Most common thyroid malignancy in iodine sufficient areas (80%)
1. History of low dose neck radiation (6.5 – 2,000 cGy) • Predominant thyroid cancer in children and patients exposed to
2. Positive family history of medullary thyroid carcinoma (MTC) or external radiation
Multiple Endocrine Neoplasia Type 2 (MEN 2) • Common in women 30 to 40 years old
3. Age: <20 or >70 years old • Clinical features:
4. Males − Euthyroid
5. 2 to 3 fold increased risk of malignancy if nodule is solid (30 – 45%) − Slow-growing painless mass in the neck
6. Growing nodule − Dysphagia, dyspnea, dysphonia (locally invasive disease)
7. Fixed nodule − LN metastases (“lateral aberrant thyroid” – cervical)
8. Cervical adenopathy common due to local and lymphatic spread
9. Persistent hoarseness, dysphonia, dysphagia, dyspnea − Distant metastases are uncommon initially but develop in
• Laboratory evaluation 20%: most common in the lungs, followed by bone, liver, and
1. Test serum TSH brain
2. If TSH is low (< 0.5 µU/ml) measure FT4 and FT3 • Diagnosis:
3. If TSH is high (> 5.0 µU/ml) measure FT4 and Thyroid Peroxidase − FNAB of thyroid mass or lymph node
Antibody − Complete neck ultrasound for:
4. Measure Serum calcitonin if family history suggests MTC (1) Evaluation of contralateral lobe
• Radionucleotide scanning – perform thyroid scintigraphy for thyroid (2) Evaluation for lymph node metastases in central and
nodule or multinodular goiter if: lateral neck compartments
1. TSH levels is below the lower limit of the normal range • Gross examination:
2. Ectopic thyroid tissue is suspected − Hard, whitish, flat, non-encapsulated
3. Retrosternal goiter is suspected − Macroscopic calcification, necrosis, cystic change
4. In iodine-deficient areas even if TSH level is normal • Microscopic examination:
• Management: FNAB is the most accurate diagnostic tool − Histological classifications:
1. Inadequate, unsatisfactory, nondiagnostic (1) Pure papillary
− Action: repeat FNAB (2) Mixed papillary and follicular
2. Benign or negative (3) Pure follicular
− Colloid nodule, Hashimoto’s thyroiditis, cyst − Cuboidal cells with pale, abundant cytoplasm, crowded
− Use of suppressive therapy with LT4: nuclei with grooving
(a) Geographic areas with iodine deficiency − Orphan Annie nuclei: intranuclear cytoplasmic inclusions
(b) Young patients with small thyroid nodules − Psammoma bodies: calcified deposits representing clumps
(c) No evidence of functional autonomy of nodule or of sloughed cells
goiter − Multifocal (85%): associated with increased risk of cervical
− Contraindications of LT4 therapy: nodal metastases
(a) Large thyroid nodules and goiters − Rarely invades adjacent structures
(b) Functionally autonomous nodules or goiters • Minimal or occult tumors or Microcarcinomas
(c) Clinically suspicious lesions − Tumors < 1 cm
(d) Inadequate cytologic sample − No evidence of local invasiveness though capsule or
(e) Postmenopausal women angioinvasion
(f) Men older then 60 years − Not associated with lymph node metastases
(g) Comorbid cardiovascular disease − Nonpalpable, incidental findings only
− Cyst: − TNM
(1) Aspirate (1) T - primary tumor
(2) If reaccumulates x 3 perform thyroidectomy Tx - can not be assessed
− Colloid nodule: T0 - no evidence of primary tumor
(1) Observe and consider T4 therapy T1 - single tumor under 2 cm, confined to the gland
(2) If growth continues with compressive symptoms T2 - single tumor >2 and < 4 cm, limited to the thyroid
perform thyroidectomy T3 - tumor > 4 cm, limited to thyroid, or minimal
3. Suspicious or indeterminate extension to strap muscle or perithyroidal soft tissue
− Cytologic results suggest a malignant lesion but do not T4a - Tumor extends beyond thyroid capsule into
completely fulfill the criteria for a definitive diagnosis subcutaneous soft tissue, larynx, trachea, esophagus,
− Follicular neoplasms, Hürthle cell tumors, atypical papillary RCN
tumors T4b - Tumor invades prevertebral fascia, mediastinal
− Action: vessels, or encases carotid
(1) Perform RAI scan (2) N - regional lymph nodes
(2) Hot nodule – perform RAI or thyroidectomy Nx - can not be assessed
(3) Cold nodule – Thyroidectomy N0 - no palpable nodes
4. Malignant or positive N1 - Regional lymph node metastases
− Primary (thyroid) or secondary (metastatic) carcinomas N1a - Metastasis in Level VI (pretracheal and
− Primary tumors: surgical consultation and thyroidectomy paratracheal, including prelaryngeal and Delphian
− Secondary tumors: search for origin lymph nodes)
Life is what you make it. Vita qua se facies est! 20
 N1b - Metastasis to other unilateral, bilateral or 3. Hürthle Cell Carcinoma
contralateral cervical or mediastinal nodes • Subtype of follicular cancer
(3) M – distant metastases • Gross and histologic examination
Mx - cannot be assessed − Vascular or capsular invasion
M0 - no evidence of distant metastases − Sheets of eosinophilic cells packed with mitochondria
M1 - distant metastases present • Clinical features:
− Multifocal and bilateral
− Do not take up RAI
− More likely to metastasize to local nodes and distant sites
− Higher mortality rate
• Surgical treatment
− Unilateral: lobectomy and isthmusectomy
− Invasive:
(1) Total thyroidectomy
(2) Routine central neck node removal
(3) Modified radical neck dissection if lateral nodes
palpable
• Surgical treatment
− Treatment of choice: Total or near total thyroidectomy for both
OTHER THYROID CANCERS
high and low risk tumors
1. Aplastic carcinoma – poor prognosis
1. Enables use of RAI to effectively detect and treat residual
• Common in women, 70 to 80 years old
thyroid tissue or metastatic disease
• Clinical features:
2. Makes Serum Tg more sensitive for recurrence or persistence
− Long standing neck mass, rapidly enlarges and may be
3. Eliminates contralateral occult cancers
painful
4. Reduces recurrence, improves survival
− Dysphonia, dysphagia, dyspnea
5. Decreaes risk of progression to anaplastic type
− Large tumor fixed to surrounding structures
6. Reduces need for reoperative surgery
− Ulcerated with areas of necrosis
− Once diagnosed by FNAB, definitive operation may be done
− Palpable lymph nodes at presentation
without confirming diagnosis with frozen section
− Evidence of metastatic spread
− Routine bilateral central neck dissection is recommended due to
− Poor prognosis
high incidence of microscopic metastases (but procedure has
• Gross and microscopic examination
concomitant increase in risk for hypoparathyroidism)
− Firm and whitish tumor
− If lateral neck is positive for metastases perform modified radical
− Sheets of cells with marked heterogeneity
or functional neck dissection
− Foci of more differentiated thyroid tumors (arise from these)
2. Follicular carcinoma – worse prognosis
• Diagnosis:
• 10% of thyroid cancers
− FNAB: characteristic giant and multinucleated cells
• Occur more commonly in thyroid deficient areas
− Incisional biopsy: confirmatory
• Common in women 50 years old
• Surgical treatment: little improvement
• Clinical features:
− Isthmusectomy with or without tracheostomy to alleviate
− Solitary thyroid nodule
tracheal obstruction
− History of rapid size increase and long standing goiter
− Thyroidectomy combined with radiation and chemotherapy
− Cervical lymphadenopathy not common upon initial
2. Medullary Carcinoma
presentation
• 5% of thyroid malignancies
− Distant metastases common upon initial presentation
• More common in females (1.5:1)
(hematogenous spread)
• Patients 50 to 60 years old
− Signs and symptoms of thyrotoxicosis (hyperfunctioning)
• Arises from Parafollicular or C cells of thyroid (ultimobranchial
• Diagnosis:
bodies) concentrated superolaterally in the thyroid lobes
− FNAB UNABLE to distinguish between benign and malignant
• Mass secretes Calcitonin, Carcinoembryonic Antigen, Calcitonin
− > 4 cm follicular tumor in older men is MORE likely malignant
Gene-related Peptide, Histaminadases, Prostaglandins E2 and F2α,
− Other methods:
Serotonin
(1) LOH (loss of heterozygosity) analysis: von Hippel-Lindau
• Most occur sporadically but 25% occur with spectrum of inherited
locus of chromosome 3p25-26
syndromes secondary to germline mutations in RET proto-
(2) Complementary DNA microarray: microRNAs 197 and
oncogene
364 upregulated in malignant follicular tumor
SYNDROME MANIFESTATIONS
• Gross and histologic examination Medullary Thyroid Carcinoma, Pheochromocytoma
− Solitary lesion MEN2A
Primary hyperparathyroidism, Lichen Planus Amyloidosis
− Encapsulated Medullary Thyroid Carcinoma, Pheochromocytoma
MEN2B
− Follicles devoid of colloid Marfanoid habitus, Mucocutaneous Ganglioneuromatosis
− Malignant: Capsular and vascular invasion Familial MTC Medullary Thyroid Carcinoma
− Minimally invasive tumors • Manifestations:
(1) Grossly encapsulated − Painful, aching neck mass associated with CLAD
(2) Microscopic invasion through tumor capsule without − Dysphagia, dyspnea, dysphonia due to local invasion
extension into parenchyma − Blood borne metastases to liver, bone, lungs
(3) Invasion into small to medium sized vessels in − Diarrhea due to increased intestinal motility and impaired
immediately outside capsule water and electrolyte flux
− Widely invasive tumors − Cushing’s syndrome (ectopic ACTH)
(1) Unencapsulated • Treatment:
(2) Large vessel invasion − Remove pheochromocytoma if present
(3) Broad areas of tumor invasion through capsule − Treatment of choice: Total thyroidectomy + Bilateral Central
• Surgical treatment Neck Node dissection
− Benign adenoma: thyroid lobectomy − Remove obviously enlarged Parathyroid glands only in those
− Older patients, > 4 cm lesion, thyroid CA diagnosed: total who are symptomatic
thyroidectomy − Post-operative Calcitonin and CEA levels
− Invasive follicular carcinoma: total thyroidectomy, Iodine 131 3. Lymphoma
for detection and ablation of metastatic disease • < 1% of thyroid malignancies
• Poor long term prognosis: • Most commonly non-Hodgkin’s B-cell type
− > 50 years old • Common in patients with Chronic Lymphocytic Thyroiditis
− > 4 cm tumor size • Treatment:
− Marked vascular invasion − Respond rapidly to chemotherapy (CHOP –
− Extrathyroidal invasion Cyclophosphamide, Doxorubicin, Vincristine, Prednisone)
− Distant metastases at time of diagnosis − Combine with radiotherapy

Life is what you make it. Vita qua se facies est! 21

QUICK VIEW: DIFFERENTIAL DIAGNOSIS FOR A THYROID MASS

DISEASE
Nodular Non-toxic Goiter
Graves Disease
(Diffuse Toxic Goiter)
Toxic Multinodular Goiter
Plummer’s Disease
(Toxic Adenoma)
Hashimoto’s Thyroiditis
(Chronic Lymphocytic
Thyroiditis)
Acute Suppurative Thyroiditis
De Quervain’s
Granulomatous Thyroiditis
(Painful Subacute Thyroiditis)
Painless Subacute Thyroiditis
Riedel’s Thyroiditis (Invasive
Fibrous Thyroiditis)
CLINICAL
ETIOLOGY DIAGNOSIS MANAGEMENT
MANIFESTATIONS
TSH stimulation secondary to Pressure sensation in neck Patchy RAIU Subtotal thyroidectomy +
inadequate TH synthesis Catarrh Usually euthyroid with Lifelong T4 replacement
Familial (enzyme, iodine Compression symptoms normal TSH, low-normal FT4
metabolism defect), endemic (+) Pemberton’s Sign FNAB if with dominant
(iodine), or sporadic nodule or enlarging nodule
CT scan
Autoimmune: Thyroid-stimulating Diffusely enlarged thyroid â TSH Propylthiouracil,
immunoglobulins and/or Exophthalmos á FT4 and FT3 Methimazole, Carbimazole
antibodies bind to the Myxedema á RAIU Propanolol
Thyrotropin receptor to stimulate (+) Thyroid receptor Radioactive iodine therapy
thyrocytes to grow and produce antibodies Total, near total, or subtotal
hormones thyroidectomy
Multiple autonomous nodules Multiple palpable â TSH Subtotal thyroidectomy
May be precipitated by: Iodide, nodules á FT4 and FT3 (Hartley-Dunhill procedure)
Amiodarone Purely thyroid signs and á RAIU
symptoms
Gene mutations of TSH receptor Single nodule usually 3 á RAIU Radioactive iodine therapy
or GSP cm or larger
Genetic predisposition Diffuse, symmetrically Initially hyper then T4 suppression
Transformation of thyroid to enlarged neck subsequently eu or Surgery
lymphoid tissue (+) Pain, tenderness hypothyroid Thyroid hormone
á TSH replacement
(+) Thyroid antibodies
Infection caused by Preceded by URTI or OM Leukocytosis Parenteral antibiotics
hematogenous or lymphatic or Severe neck pain FNAB with Gram’s stain, Drainage of abscess
direct spread, trauma, or radiating to jaws or ear culture, cytology Complete resection of
immunosuppression Fever, chills CT-scan Pyriform sinus fistula if present
Common: Streptococcus, Odynophagia Barium swallow
anaerobes Dysphonia
Viral or post-viral inflammatory Preceded by URTI Initially hyper then eu then
response Neck pain radiating to hypo then resolution to Symptomatic treatment
Genetic predisposition: HLA B35 the jaws or ear euthyroidism Aspirins or NSAIDs
Enlarged, tender, firm â TSH Steroids for severe pain
thyroid á T4 and T3 Short term TH replacement
ESR > 100 Thyroidectomy: if prolonged
â RAIU and unresponsive
Autoimmune Normal sized or minimally â TSH Beta-blockers
Sporadic or post-partum enlarged, slightly firm, á T4 and T3 TH replacement
non-tender thyroid gland Normal ESR Thyroidectomy, RAI ablation
â RAIU if recurrent and disabling
Autoimmune Painless, hard, anterior Open thyroid biopsy Surgery
Thyroid parenchyma replaced neck mass TH replacement +
by fibrous tissue invading Hard, woody thyroid Corticosteroids
adjacent tissue gland with fixation to
surrounding structures
Compression symptoms

REFERENCES:
1. Role of Surgery in Benign and Malignant Thyroid Diseases by Dr. E.H.
Nucum, Department of Surgery Faculty of Medicine and Surgery
University of Santo Tomas
2. The Thyroid Gland by Dr. S. Kho, Department of Internal Medicine
Section of Endocrinology Faculty of Medicine and Surgery University of
Santo Tomas
3. Brunicardi, C.F., et al. (2010). Schwartz’s Principles of Surgery, 19th ed.
McGraw-Hill Companies Inc.: New York.
4. Foster, C., Mistry, N.F., et al. (2010). The Washington Manual of Medical
Therapeutics, 33rd ed. Lippincott Williams & Wilkins: Philadelphia.
5. Longo, D.L., Fauci, A.C., Kasper, D.L, et al. (2013). Harrison’s Principles of
Internal Medicine, 18th edition. McGraw-Hill Companies Inc.: New York.
6. Gray’s Anatomy for Students by Richard L. Drake, Wayne Vogl, and
Adam W.M. Mitchell

Life is what you make it. Vita qua se facies est! 22