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

CAGS review

·       Workup of paraesophageal hernia/gastric volvulus

·       CT abdo/pelvis vs. Gastro

·       TPN

·       Brachial plexus

Stress ulceration

Gastric pH needs to be >4 to prevent stress ulcer formation
- incidence of bleeding is 2-3%
- most common indication for stress ulcer prophylaxis is respiratory failure (followed by shock/hypotensions, sepsis and neurotrauma)

Agents used for prophylaxis are:
- H2 blockers
- sucralfate (higher incidence of bleeding compared to H2 blocker)
- PPIs

- H2 and PPIs are equally effective in stress ulcer prophylaxis and have no difference in nosocomial pneumonia

Sucralfate vs. Ranitidine:
- RCT performed NEJM 1998
- ranitidine has 50% decreased ulcer rate (1.7 vs 3.8%) compared to sucralfate
- does not significantly increase ventilator associated pneumonia rate (16 vs 19%)

Inverse Ratio ventilation

Technique of reversing length of inspiration:expiration from 1:2 to 2:1
- increases the time for positive-pressure inspiration

- what clinical scenarios would this be beneficial?
- decreased expiratory time can lead to permissive hypercapnia and reduce barotrauma

Consequence of this type of ventilation:
- positive intra-thoracic pressure can result in decreased pre-load
- can be uncomfortable and cause anxiety for pt (requiring increased sedation)
- may not allow for adequate expiratory time resulting in stacked breaths and auto-PEEP

Adrenal Metastases:

Most common cancer metastasizing to the adrenals:
- Lung ca
- RCC
- melanoma
- breast ca
- gastrointestinal ca
- HCC
- lymphoma

Work-up:
- patients with a solitary adrenal mass and symptoms suggestive of malignancy should have screening colonoscopy, mammography and CXR to try and identify the primary tumor
- PET scan may be helpful to identify the primary disease
- FNA can be performed: but only after a pheo has been ruled out

Presence of a solitary met - may benefit from adrenalectomy
- usually small and contained within capsule.
- lap adrenalectomy has been shown to have an equally effective outcome as open adrenalectomy
- 5 year survival 25%