BiRADS classification

0: incomplete assessment
1: negative (normal breast)
2: benign finding
3: likely benign finding (short-interval follow-up suggested)
4: suspicious finding (biopsy suggested)
5: highly suspicious of malignant finding

Branches of External Carotid Artery

"Sally Ann Likes Flirting On Philadelphia's Main Street"
- Superior thyroid
- Ascending pharyngeal
- Lingual
- Facial
- Occipital
- Posterior auricular
- Maxillary
- Superficial temporal

GIST Metastatic Risk Criteria

Gastrointestinal Stromal Tumors (GIST)

- Can arise from any mesenchymal component of gastric wall (hence previous designation of leiomyoma/leimyosarcoma)
- 3% of all gastric malignancies
- 50% of GIST in the stomach
- Carney triad: nonhereditary syndrome in young females (children) - gastric GIST, paraganglioma, pulmonary chondroma.
- increased incidence of GIST in pts with NF1
- Main route of metastasis is hematologic.  Lymphatic dissemination rare (<10%) therefore extensive lymphadenectomy not indicated
- presentation will largely depend on whether mass enalrges intraluminally or extraluminally

Metastases:
- 50% present with mets
- metastases can present as multiple serosal nodules throughout the peritoneal cavity or nodules in the liver. Extra-abdominal mets are rare.

Diagnosis:
- needle biopsy is not indicated, risks seeding or tumor rupture: soft and fragile tumor
- ? if unresectible then perhaps consider biopsy to justify upfront imatinib ?make the lesion resectable
- low risk metastases: <5cm, <5 mitoses/50 HPF

Pathology:
- Firm gray-white masses.
- often have a pseudocapsule that separates tumor from normal smooth muscle
- 80% have gain of function mutation of tyrosine kinase c-KIT, 8% have mutation that activates tyrosine kinase PDGFRA
- common stem cell - interstitial cells of Cajal

Adjunctive Therapy:
- NOT radiosensitive
- traditional chemo does not improve survival
- Imatinib: small molecule inhibitor of c-kit receptor

Survival:
- 5 year survival is 42% with complete resection
- survival drops to 9% with incomplete resection (?pre-Gleevec era)

Williams Tracheostomy

Supplies.
Headlamp
Cautery
Extra retractors - Langenbach
Split drape
Dentals

Position pt with roll transversely across shoulders
Prep neck
Setup instruments and prepare dental rolls

STEPS:
- Transverse skin incision
- "Defat" wound
- Place langenbach retractors in wound and incise linea alba with catery
- Dissect down to thyroid capsule
- Try to retract thyroid gland away and off of trachea or else go through it slowly with cautery
- Use dentals to push of pretracheal fascia
- Make transverse incision along inter ring space
- Cut/strech with mets, retractors
- Insert tube inflate cuff , secure in place with neck strap then place gauze.

- Posted from iPhone

Williams post op thyroid hypocalcemia

Calcium carbonate 1 g po tid
Rocalcitrol 0.25 mg po bid x 2 week
Syntheoid .1 mg po qd x 8 wkd
Fu 6 wkd
Ca pth qtues and Thursday
Check tsh in 5 weeks



- Posted from iPhone

Differential Parotid gland masses

Benign:
- Pleimorphic adenoma
- Warthin's tumor
- Oncocytoma
- Basal cell adenoma
- hemangioma
- myeloepithelioma

Malignant:
- Mucoepidermoid ca
- Adenoid cystic ca
- Adenoca
- mixed malignant (malignant transformation of pleimorphic adenoma (10% over 15 years))
- Acinic cell ca
- squamous cell ca
- Mets
- Lymphoma
- Sarcoma

DCW Thyroid

- mark and infiltrate with 20cc local
- Transverse neck incision with scalpel
- create flaps using scalpel +/- cautery
- use russian foreceps to open linea cervicalis

- Cautery create areolar plane between straps and thyroid
- Davey-Langenbach retraction to create plane
- Finger on thyroid to roll up and out

- start at superior pole and take superior thyroid artery vessels carefully with mccabe dissector
- once near cricothyroid membrane then go work on inferior pole
- identify nerve at cricothyroid membrane along with parathyroid
- inferior para usually in the thyrothymic ligament
- save the attachement at the cricothyroid membrane for last
- clip or tie off everything
- leave a ?drain in every case - remove POD#1
- close line with vicryl
- interrupted vicryl for platysma, vicryl for skin and perfect steris

Anatomical Landmarks During a Radical Neck Dissection

Platysma
External jugular vein
Anterior jugular vein
Greater Auricular nerve
Marginal mandibular branch of the facial nerve
Maxillary artery
Facial vein
Sternocleidomastoid - divide clavicular head in radical neck dissection
Trapezius muscle
Spinal accessory nerve
Omohyoid muscle - divided
Brachial plexus
Middle and anterior scalene muscles
Brachial plexus
phrenic nerve
Carotid sheath
vagus nerve
internal jugular vein - divided in radical neck dissection
common carotid artery
Superior thyroid artery
Hypoglossal nerve
Branches of cervical plexus
Anterior belly of digastric
Myelohyoid muscle
Hyoid bone
Submandibular salivary gland
Salivary gland duct
Lingual nerve
Posterior belly of digastric
Tail of parotid gland

Finding the Parathyroid Glands

Superior:

Inferior:
- identify the thyrothymic ligament - inf para usually located within or adjacent to thyrothymic ligament

Remnant Radioablation after total-thyroidectomy for Papillary Thyroid Ca

Brisy question: What % of pts will have radionucleotide uptake after a "total-thyroidectomy"?

Debate remains surrounding the need for radioablation after total thyroidectomy for papillary thyroid ca.

Hay argues that there is no need for radioablation:
- retrospective study from 1940's to present where there has been increased frequency of radioablation has not correlated into increased survival or decreased tumor recurrence.

Mazzaferri argues that radioablation should be performed:
- large remnant can obscure I-131 uptake in cervical or lung mets
- Found that in pts with tumors >1.5cm - cancer recurrence, distant recurrence and cancer death rates were lower after remnant ablation
- They conceed that not everyone has found this and believe that perhaps groups such as Hay had more aggressive total thyroidectomies that left less remnant tissue

Complications associated with I-131 radioablation:
Acute:
Chronic:

Extent of Surgery for Papillary Thyroid Cancer

Main debate centres around management for T2 (1-4cm) tumors with no evidence of metastases

Aggressive surgical therapy (Hay/Mayo Clinic):
- microscopic disease present in both lobes regardless of whether macroscopic disease evident bilaterally
- disease is aggressive in certain subpopulations: older men, pts with large tumors, tumors that have invaded adjacent structures

Hay et al, WJS 2002:
- retrospective review from 1940's to present time.
- trend in 1940's to perform lobectomy yielded higher cause-specific mortality and tumor-recurrence (14% vs. 2%) as compared to 1950's and beyond where total thyroidectomy was favoured.
- addition of radioiodine remnant ablation in past few decades has not made a difference in mortality or recurrence.
Conclusion: near-total thyroidectomy and conservative nodal excision favoured management for papillary thyroid ca

Conservative surgical therapy:
- likelihood pt will develop clinically evident disease after lobectomy is only 5%
- recurrent disease can be managed by completion thyroidectomy
- majority of thyroid carcinomas grow slowly, few patients die from disease
- complications of total thyroidectomy (higher in inexperienced surgeon's hands)

Central compartment LN:

- involved in 50-80% of cases

Current NCCN guidelines recommends (2001):
- Total thyroidectomy
- if LN involved: bilateral central compartment LN dissection +/- lateral modified radical LN dissection
- ?do new guidelines advocated routine central compartment LN dissection that most people are doing?

Non-recurrent Laryngeal nerve

- rare: 1%

- Direct laryngeal nerve that comes off the vagus.

- more common on the right

- resutls of an anomalous origin of the right subclavian artery off the descending aorta

- if not recognized will result in division thinking it is the inferior thyroid artery - and it is the reason it is important to identify the RLN before dividing vascular structures

Thyroid anatomy

Superior Mesenteric Artery Anatomy

Differentiating Hyperthyroid Disease States

Breast Imaging

Modality is dependent on age.

Younger patients have dense breasts making mammography difficult to interpret.

Age<30: U/S
Age 30-39: Mammography and targeted U/S
Age >40: bilateral mammogram with targeted ultrasound

MRI should be reserved for diagnostic problems.

Breast Biopsy Techniques

Stereotactic core biopsy:
Pt cooperation is necessary to obtain needle guided core biopsy.
Pts breast must be compressed for 20-40 minutes
Factors which will prevent the ability to achieve adequate samping are
- inability to lie prone
- chronic cough or anxiety
- BMI - tables can generally only accomodate ~300lbs
- breasts too thin

Ultrasound guided core biopsy:
alternative for lesions that can be visualized by this technique
avoids the need for breast compression
ideal for:
- lesions close to chest wall
- superficial breast lesions
- near the nipple

Correlation of radiographic findings with pathologic diagnosis is essential to avoid missed cancers.
- 23% of non-diagnostic specimens are found to be malignant
- 10-20% of pts with DCIS diagnosed by a 14G core biopsy will have foci of invasive disease at surgery

Indications for Surgical Biopsy:
- discordance between imaging findings and pathologic diagnosis
- atypical hyperplasia, ductal or lobular (risk of adjacent intraductal or invasive ca 20-50%)
- lobular carcinoma in situ (increased risk of adjacent disease)
- papillary lesions (core cannot differentiate between benign and malignant)
- phyllodes tumor (core cannot differentiate between benign and malignant)
- radial scar (cannot differentiate between fragments of radial scar and well-differentiated carcinomas)

Needle-track seeding:
- it is not necessary to resect the core biopsy needle track.
- 42% of pts <15 days after core biopsy will have needle track seeding.  However this decreases to 15% after 28 days.  This suggests that these cells are not viable and that over time they will not survive.

Complications:
- risk of hematoma and infection: 2/1000 each
- mild bruising, mild tenderness
- pneumothorax possible but extremely rare