C. Nodal Status: A. Mitotic Number B. Grade

A 43 year old lady has recently undergone a wide local excision and sentinel lymph
node biopsy for carcinoma of the breast. Of the factors listed below, which will
provide the most important prognostic information?
A. Mitotic number
B. Grade
C. Nodal status
D. Size
E. Oestrogen receptor status

Nodal status is the single most
important prognostic factor in breast
cancer.
Theme from April 2012 Exam

Nodal status is important because it serves as a marker of tumour metastatic potential.
This translates to survival advantages of up to 40% at five years. Both grade and size
are of secondary importance as they both less concerning in the absence of nodal
involvement.
Breast cancer
 Commoner in the older age group

 Invasive ductal carcinomas are the most common type. Some may arise as a
result of ductal carcinoma in situ (DCIS). There are associated carcinomas
of special type e.g. Tubular that may carry better prognosis.
 The pathological assessment involves assessment of the tumour and lymph
nodes, sentinel lymph node biopsy is often used to minimise the morbidity of
an axillary dissection.
 Treatment, typically this is either wide local excision or mastectomy. There
are many sub types of both of these that fall outside of the MRCS. Some key
rules to bear in mind.
 Whatever operation is contemplated the final cosmetic outcome does have a
bearing. A women with small breasts and a large tumour will tend to fare
better with mastectomy, even if clear pathological and clinical margins can be
obtained. Conversely a women with larger breasts may be able to undergo
breast conserving surgery even with a relatively large primary lesion (NB
tumours >4cm used to attract recommendation for mastectomy). For screen
detected and impalpable tumour image guidance will be necessary.
 Reconstruction is always an option following any resectional procedure.
However, its exact type must be tailored to age and co-morbidities of the
patient. The main operations in common use include latissimus dorsi
myocutaneous flap and sub pectoral implants. Women wishing to avoid a
prosthesis may be offered TRAM or DIEP flaps.
Surgical options
Mastectomy vs Wide local excision
Mastectomy Wide Local Excision

Multifocal tumour Solitary lesion
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast
DCIS >4cm DCIS <4cm
Patient Choice Patient choice
Central lesions may be managed using breast conserving surgery where an

acceptable cosmetic result may be obtained, this is rarely the case in small breasts
A compelling indication for mastectomy, a larger tumour that would be unsuitable for
breast conserving surgery
Image sourced from Wikipedia
Whatever surgical option is chosen the aim should be to have a local recurrence rate
of 5% or less at 5 years [1].
Nottingham Prognostic Index

The Nottingham Prognostic Index can be used to give an indication of survival. In this
system the tumour size is weighted less heavily than other major prognostic
parameters.
Calculation of NPI
Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From
table below).
Lymph nodes involved Grade

Score
1 0 1
2 1-3 2
3 >3 3
Prognosis
Score Percentage 5 year survival

2.0 to 2.4 93%
2.5 to 3.4 85%
3.5 to 5.4 70%
>5.4 50%
This data was originally published in 1992. It should be emphasised that other factors
such as vascular invasion and receptor status also impact on survival and are not
included in this data and account for varying prognoses often cited in the literature.
References
Surgical guidelines for the management of breast cancer, Association of Breast
Surgery at BASO 2009, Eur J Surg Oncol
(2009), doi:10.1016/j.ejso.2009.01.008
Theme: Management of nipple discharge
A. Prescribe danazol
B. Microdochectomy
C. Total duct excision
D. Cytology of duct fluid
E. Core biopsy
F. Prescribe co-amoxiclav
G. Reassure and discharge
H. Mastectomy
What is the best management for each nipple discharge presentation? Each option
may be used once, more than once or not at all.
2. A 23 year old women with greenish nipple discharge on one occasion. Clinical
examination of the breast is normal. Ultrasound report is U1.
You answered Cytology of duct fluid
The correct answer is Reassure and discharge
This is likely to be simple duct ectasia and U1 (normal USS) coupled with
normal examination would favor discharge from clinic. Mammography is
generally unhelpful in this age group
3. A 43 year old women has had recurrent episodes of periductal mastitis. She has
received multiple courses of antibiotics and is troubled by persisting green
nipple discharge. Clinical examination reveals green nipple discharge, but no
discrete lump. Imaging with mammography and ultrasound is reassuring (U2,
M2)
You answered Reassure and discharge
The correct answer is Total duct excision
This woman has troublesome duct ectasia and total duct excision is warranted.
4. A 55 year old women complains of nipple discharge. This was blood stained on
one occasion. But not subsequently. Clinical examination shows clear fluid but
no discrete lump. Imaging with ultrasound and mammography is normal.
You answered Cytology of duct fluid
The correct answer is Microdochectomy
Although this is likely to be benign disease, her age coupled with an episode of
blood stained discharge would attract a recommendation for microdochectomy.
She may have an intraductal papilloma. But the concern would be DCIS.
Nipple discharge
Causes of nipple discharge

Physiological During breast feeding
Galactorrhoea Commonest cause may be response to emotional events, drugs
such as histamine receptor anatagonists are also implicated
Hyperprolactinaemia  Commonest type of pituitary tumour
 Microadenomas <1cm in diameter
 Macroadenomas >1cm in diameter
 Pressure on optic chiasm may cause bitemporal
hemianopia
Mammary duct  Dilatation breast ducts.

ectasia  Most common in enopausal women
 Discharge typically thick and green in colour
 Most common in smokers
Carcinoma  Often blood stained

 May be underlying mass or axillary lymphadenopathy
Intraductal papilloma  Commoner in younger patients

 May cause blood stained discharge
 There is usually no palpable lump
Assessment of patients
 Examine breast and determine whether there is mass lesion present

 All mass lesions should undergo Triple assessment.
Reporting of investigations
Where a mass lesion is suspected or investigations are requested these are prefixed
using a system that denotes the investigation type e.g. M for mammography, followed
by a numerical code as shown below:
1 No abnormality
2 Abnormality with benign features
3 Indeterminate probably benign
4 Indeterminate probably malignant
5 Malignant
Management of non malignant nipple discharge
 Exclude endocrine disease

 Nipple cytology unhelpful
 Smoking cessation advice for duct ectasia
 For duct ectasia with severe symptoms, total duct excision may be warrented.
Theme: Breast disease
A. Ductal carcinoma in situ

B. Lobular carcinoma in situ
C. Invasive ductal carcinoma
D. Invasive lobular carcinoma
E. Inflammatory carcinoma
F. Phyllodes tumour
G. Paget's disease of the nipple
H. Fibroadenoma
I. Mucinous breast carcinoma
From the list please select the most likely diagnosis for the scenario given. Each
diagnosis may be used once, more than once or not at all.
1. A 32 year old Indian lady presents with breast lump. She has a 4 month old
child. Clinically she has jaundice and there is erythema of the left breast.
You answered Paget's disease of the nipple
The correct answer is Inflammatory carcinoma
Inflammatory breast cancers have an aggressive nature. Dissemination occurs

early and is more resistant to adjuvent treatments than other types of breast
cancer. Often occurs in pregnancy or lactation.
2. A 72 year old female presents with a painless breast lump. Clinically she has a
4cm diameter irregular breast mass, with no other palpable masses..
You answered Lobular carcinoma in situ
The correct answer is Invasive ductal carcinoma
A post menopausal woman is more likely to have a ductal carcinoma and they
tend to occur at a single focus within the breast.
3. A 72 year old woman presents with 2 breast lumps. She has a history of breast
cancer in the opposite breast 5 years ago.
Invasive lobular carcinoma
This is likely to be an invasive lobular carcinoma, mainly due to the multifocal

lesions and the history of previous breast cancer in the opposite breast.
Breast cancer

Surgical options

DCIS >4cm DCIS <4cm



parameters.
Calculation of NPI
table below).

Score
1 0 1
2 1-3 2
3 >3 3
Prognosis

2.0 to 2.4 93%
2.5 to 3.4 85%
3.5 to 5.4 70%
>5.4 50%
References
(2009), doi:10.1016/j.ejso.2009.01.008
A 72 year old female is found to have a malignant lesion in her left arm. She had a
mastectomy of the left breast 10 years ago and has chronic lymph oedema of the left
arm. What is the most likely cause of the malignancy?
A. Lymphangiosarcoma
B. Lymphoma
C. Myeloma
D. Angiomyolipoma
E. Giant cell tumour

Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an
aggressive malignancy.
Lymphoedema
 Due to impaired lymphatic drainage in the presence of normal capillary

function.
 Lymphoedema causes the accumulation of protein rich fluid, subdermal
fibrosis and dermal thickening.
 Characteristically fluid is confined to the epifascial space (skin and
subcutaneous tissues); muscle compartments are free of oedema. It involves
the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the
dorsum of the foot and the skin cannot be pinched due to subcutaneous
fibrosis.
Causes of lymphoedema
Primary  Congenital < 1 year: sporadic, Milroy's disease

 Onset 1-35 years: sporadic, Meige's disease
 > 35 years: Tarda
Secondary  Bacterial/fungal/parasitic infection (filariasis)

 Lymphatic malignancy
 Radiotherapy to lymph nodes
 Surgical resection lymph nodes
 DVT
 Thrombophlebitis
Indications for surgery
 Marked disability or deformity from limb swelling

 Lymphoedema caused by proximal lymphatic obstruction with patent distal
lymphatics suitable for a lymphatic drainage procedure
 Lymphocutaneous fistulae and megalymphatics
Procedures
Homans operation Reduction procedure with preservation of overlying skin (which
must be in good condition). Skin flaps are raised and the
underlying tissue excised. Limb circumference typically reduced
by a third.
Charles operation All skin an subcutaneous tissue around the calf is excised down to
the deep fascia. Split skin grafts are placed over the site. May be
performed if overlying skin is not in good condition. Larger
reduction in size than with Homans procedure.
Lymphovenous Identifiable lymphatics are anastomosed to sub dermal venules.
anastamosis Usually indicated in 2% of patients with proximal lymphatic
obstruction and normal distal lymphatics.
A 58 year old male is referred to endocrinology clinic for a parathyroidectomy by the
F1 in medicine. His corrected calcium is 2.85 (2.2-2.6), PTH 7.5 (3-7) and 24h
urinary calcium is 1.5 (2.5-7.5). What is the diagnosis?
A. Primary hyperparathyroidism
B. Secondary hyperparathyroidism
C. Tertiary hyperparathyroidism
D. Familial hypocalciuric hypercalcaemia
E. Hypercalacemia associated with malignancy
This F1 should have spoken to his senior. This patient has familial hypocalciuric
hypercalcaemia, which requires no further action.
Parathyroid glands and disorders of calcium metabolism
Hyperparathyroidism
Disease type Hormone profile Clinical features Cause
Primary  PTH (Elevated)  May be Most cases due to
hyperparathyroidism  Ca2+ (Elevated) asymptomatic if solitary adenoma
 Phosphate mild (80%), multifocal
(Low)  Recurrent disease occurs in
 Serum abdominal pain 10-15% and
Calcium : (pancreatitis, renal parathyroid
Creatinine colic) carcinoma in 1% or
clearance ratio  Changes to less
> 0.01 emotional or
cognitive state
Secondary  PTH (Elevated)  May have few Parathyroid gland
hyperparathyroidism  Ca2+ (Low or symptoms hyperplasia occurs
normal)  Eventually may as a result of low
 Phosphate develop bone calcium, almost
(Elevated) disease, osteitis always in a setting
 Vitamin D fibrosa cystica and of chronic renal
levels (Low) soft tissue failure
calcifications
Tertiary  Ca2+ (Normal or  Metastatic Occurs as a result
hyperparathyroidism high) calcification of ongoing
 PTH (Elevated)  Bone pain and / hyperplasia of the
 Phosphate or fracture parathyroid glands
levels  Nephrolithiasis after correction of
 Pancreatitis underlying renal
(Decreased or disorder,
Normal) hyperplasia of all 4
 Vitamin D glands is usually the
(Normal or cause
decreased)
 Alkaline
phosphatase
(Elevated)
Differential diagnoses
It is important to consider the rare but relatively benign condition of benign familial
hypocalciuric hypercalcaemia, caused by an autosomal dominant genetic disorder.
Diagnosis is usually made by genetic testing and concordant biochemistry (Serum
Calcium : Creatinine clearance ratio <0.01-distinguished from primary
hyperparathyroidism).
Treatment
Primary hyperparathyroidism
 Elevated serum Calcium > 1mg/dL above normal

 Hypercalciuria > 400mg/day
 Creatinine clearance < 30% compared with normal
 Episode of life threatening hypercalcaemia
 Nephrolithiasis
 Age < 50 years
 Neuromuscular symptoms
 Reduction in bone mineral density of the femoral neck, lumbar spine, or distal
radius of more than 2.5 standard deviations below peak bone mass (T score
lower than -2.5)
Secondary hyperparathyroidism
Usually managed with medical therapy.
Indications for surgery in secondary (renal) hyperparathyroidism:
 Bone pain
 Persistent pruritus
 Soft tissue calcifications
Tertiary hyperparathyroidism
Usually treatment is surgical
The presence of an autonomously functioning parathyroid gland may require surgery.
If the culprit gland can be identified then it should be excised. Otherwise total
parathyroidectomy and re-implantation of part of the gland may be required.
References
1. Pitt S et al. Secondary and Tertiary Hyperparathyroidism, State of the Art Surgical
Management. Surg Clin North Am 2009 Oct;89(5):1227-39.
2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J

Endocrinol 2011; 2011: 251410.
Theme: Management of breast cancer
A. Simple mastectomy alone

B. Radical mastectomy alone
C. Simple mastectomy and sentinel lymph node biopsy
D. Wide local excision and sentinel lymph node biopsy
E. Simple mastectomy and axillary node clearance
F. Radical mastectomy and axillary node clearance
G. Wide local excision and axillary node clearance
H. Wide local excision alone
Please select the most appropriate treatment for the situation described. Each option
6. A 44 year old lady presents with a mass in the upper outer quadrant of her right
breast. Imaging, histology and clinical examination confirm a 1.5cm malignant
mass lesion with no clinical evidence of axillary nodal disease.
Wide local excision and sentinel lymph node biopsy
A small peripheral lesion such as this would usually be suitable for breast
conserving surgery. Since imaging and clinical examination is not suspicious for
axillary disease, a sentinel lymph node biopsy should be performed.
7. An infirm 79 year old lady presents with a mass lesion in the middle of her right
breast. A core biopsy is performed which confirms a low grade multifocal
ductal carcinoma in situ.
Simple mastectomy alone
Multifocal DCIS is usually treated with a simple mastectomy. A wide local

excision is not a sensible option where multifocal disease is present.
8. A 39 year old lady presents with a mass lesion in her right breast. Clinical
examination, biopsy and imaging confirm a 2.5 cm lesion in the upper inner
quadrant of her right breast and a 1.5 cm lesion at the central aspect of the same
breast. Her axilla shows lymphadenopathy and a fine needle aspirate from the
node shows malignant cells.
You answered Radical mastectomy and axillary node clearance
The correct answer is Simple mastectomy and axillary node clearance
A combination of established axillary disease and multifocal invasive lesions

attracts an indication for mastectomy and axillary clearance. A radical
mastectomy is less frequently indicated in modern surgical practice, disease that
is locally advanced is often best downstaged using medical therapy, rather than
embarking on the operations for breast cancer that were first popularised over
100 years ago.
Breast cancer management
 Surgery is performed in most patients suffering from breast cancer.

 Chemotherapy may be used to downstage tumours and allow breast
conserving surgery. Hormonal therapy may also be used for the same
purposes.
 Radiotherapy is given to all patients who have undergone breast conserving
surgery.
 Patients who have undergone mastectomy may be offered a reconstructive
procedure either in conjunction with their primary resection or as a staged
procedure at a later date.
Surgical options

DCIS >4cm DCIS <4cm
Central lesions may be managed using breast conserving surgery, where an

Axillary disease
 As a minimum, all patients with invasive breast cancer should have their axilla
staged. In those who do not have overt evidence of axillary nodal involvement
this can be undertaken using sentinel lymph node biopsy.
 Patients with a positive sentinel lymph node biopsy or who have imaging and
cytological or histological evidence of axillary nodal metastasis should
undergo axillary node clearance.
 Axillary node clearance is associated with the development of lymphoedema,
increased risk of cellulitis and frozen shoulder.
A 50 year old lady is commenced on tamoxifen for the treatment of an oestrogen

receptor positive breast cancer. Which of the following malignancies are associated
with tamoxifen use?
A. Adenocarcinoma of the colon
B. Hodgkins lymphoma
C. Adenocarcinoma of the lung
D. Ovarian cancer
E. Endometrial cancer
Tamoxifen is an oestrogen receptor antagonist in breast tissues. However, at other

sites, such as the endometrium it may act as an agonist. Hence the reason for
increasing risk of endometrial cancer.
Tamoxifen
 Synthetic partial oestrogen agonist, acts primarily by binding to the oestrogen

receptor.
 Half life of 7 days, takes 4 weeks for drug to reach plasma steady state.
 Should usually be considered in patients with oestrogen receptor positive
tumours (alternative agents may be preferred in some groups).
 Although antagonistic with respects to breast tissue tamoxifen may serve as an
agonist at other sites. Therefore risk of endometrial cancer is increased,
preservation of bone density and decreased cardiovascular risks.
 Climateric side effects are common, 3% stop taking the drug because of these.
 Aromatase inhibitors are an alternative class of drugs, these work by blocking
the peripheral aromatization of androgens (post menopausal women produce
oestrogens in this way). They may treat cancers for which tamoxifen is no
longer effective.
Theme: Thyroid nodules
A. Toxic adenoma
B. Anaplastic carcinoma of thyroid
C. Follicular carcinoma of thyroid
D. Papillary carcinoma of thyroid
E. Medullary carcinoma of thyroid
F. Thyroid lymphoma
G. Multinodular goitre
H. Parathyroid gland tumour
For each scenario please select the most likely underlying diagnosis. Each option may
be used once, more than once or not at all.
10. A 52 year old woman with known Hashimotos thyroiditis presents with a neck
swelling. She describes it as rapidly increasing in size over 3 months and she
complains of dysphagia to solids. On examination there is an asymmetrical
swelling of the thyroid gland.
You answered Medullary carcinoma of thyroid
The correct answer is Thyroid lymphoma
Thyroid lymphoma (Non Hodgkin's B cell lymphoma) is rare. It should be

considered in patients with a background of Hashimoto's thyroiditis and a rapid
growth in size of the thyroid gland. Diagnosis can be made with fine-needle
aspiration or core needle biopsy; however an incisional biopsy may be needed.
Radiotherapy is the main treatment option.
11. A 52 year old woman presents with a neck swelling. On examination she is
noted to have single nodule on the thyroid gland. A CXR shows two mass
lesions.
You answered Thyroid lymphoma
The correct answer is Follicular carcinoma of thyroid
A solitary nodule with signs of haematogenous spread indicates a follicular

tumour. Note that papillary tumours tend to be multinodular and spread via the
lymphatic system.
12. A 52 year old woman presents with a neck swelling. Her GP reports that her
TSH value is low at 0.01. A scintigraphy demonstrates a hot nodule.
Toxic adenoma
This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a
toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules.
Thyroid disease
Patients may present with a number of different manifestations of thyroid disease.

They can be broadly sub classified according to whether they are euthyroid or have
clinical signs of thyroid dysfunction. In addition it needs to be established whether
they have a mass or not.
Assessment
 History
 Examination including USS
 If a nodule is identified then it should be sampled ideally via an image guided
fine needle aspiration
 Radionucleotide scanning is of limited use
Thyroid Tumours
 Papillary carcinoma
 Follicular carcinoma
 Anaplastic carcinoma
 Medullary carcinoma
 Lymphoma's
Multinodular goitre
 One of the most common reasons for presentation

 Provided the patient is euthyroid and asymptomatic and no discrete nodules
are seen, they can be reassured.
 In those with compressive symptoms surgery is required and the best
operation is a total thyroidectomy.
 Sub total resections were practised in the past and simply result in recurrent
disease that requires a difficult revisional resection.
Endocrine dysfunction
 In general these patients are managed by physicians initially.

 Surgery may be offered alongside radio iodine for patients with Graves
disease that fails with medical management or in patients who would prefer
not to be irradiated (e.g. pregnant women).
 Patients with hypothyroidism do not generally get offered a thyroidectomy.
Sometimes people inadvertently get offered resections during the early phase
of Hashimotos thyroiditis, however, with time the toxic phase passes and
patients can simply be managed with thyroxine.
Complications following surgery
 Anatomical such as recurrent laryngeal nerve damage.

 Bleeding. Owing to the confined space haematoma's may rapidly lead to
respiratory compromise owing to laryngeal oedema.
 Damage to the parathyroid glands resulting in hypocalcaemia.
Further sources of information

1. http://www.acb.org.uk/docs/TFTguidelinefinal.pdf- Association of Clinical
Biochemistry guidelines for thyroid function tests.
2. British association of endocrine surgeons website- http://www.baets.org.uk

Which investigation is best for initial assessment of recurrence of follicular carcinoma
of the thyroid?
A. Free T4
B. Thyroid stimulating hormone
C. Scintigraphy
D. Serum thyroglobulin
E. USS thyroid gland
Elevated thyroglobulin levels raises suspicion of recurrence.
Thyroid malignancy
Papillary carcinoma
 Commonest sub-type
 Accurately diagnosed on fine needle aspiration cytology
 Histologically they may demonstrate psammoma bodies (areas of
calcification) and so called 'orphan Annie' nuclei
 They typically metastasise via the lymphatics and thus laterally located
apparently ectopic thyroid tissue is usually a metastasis from a well
differentiated papillary carcinoma.
Follicular carcinoma
 Are less common than papillary lesions

 Like papillary tumours they may present as a discrete nodule. Although they
appear to be well encapsulated macroscopically there invasion on microscopic
evaluation.
 Lymph node metastases are uncommon and these tumours tend to spread
haematogenously. This translates into a higher mortality rate.
 Follicular lesions cannot be accurately diagnosed on fine needle aspiration
cytology and thus all follicular FNA's will require at least a hemi
thyroidectomy.
Anaplastic carcinoma
 Less common and tend to occur in elderly females

 Disease is usually advanced at presentation and often only palliative
decompression and radiotherapy can be offered.
Medullary carcinoma
 These are tumours of the parafollicular cells ( C Cells) and are of neural crest
origin.
 The serum calcitonin may be elevated which is of use when monitoring for
recurrence.
 They may be familial and occur as part of the MEN -2A disease spectrum.
 Spread may be either lymphatic or haematogenous and as these tumours are
not derived primarily from thyroid cells they are not responsive to radioiodine.
Lymphoma
 These respond well to radiotherapy

 Radical surgery is unnecessary once the disease has been diagnosed on biopsy
material. Such biopsy material is not generated by an FNA and thus a core
biopsy has to be obtained (with care!).
A 33 year old lady attends the clinic with a 3 month history of palpitations and
irritability. Her thyroid function, PTH and calcium are measured:
Thyroid function
Free T4 40 pmol/L
TSH < 0.1 miu/L
Free T3 25 p mol/L
PTH 10pg/ml
(Normal values listed in reference range link)
What is the most likely diagnosis?
A. Hypothyroidism
B. Hyperthyroidism
C. Hypoparathyroidism
D. Hyperparathyroidism
E. Euthyroid
Theme from April 2012 Exam

Elevated T4 and suppressed TSH makes this the most likely diagnosis. The PTH level
is normal.
Hyperthyroidism
Causes of hyperthyroidism include:
 Diffuse toxic goitre (Graves Disease)

 Toxic nodular goitre
 Toxic nodule
 Rare causes
Graves disease
Graves disease is characterised by a diffuse vascular goitre that appears at the same
time as the clinical manifestations of hyperthyroidism. It is commonest in younger
females and may be associated with eye signs. Thyrotoxic symptoms will
predominate. Up to 50% of patients will have a familial history of autoimmune
disorders. The glandular hypertrophy and hyperplasia occur as a result of the thyroid
stimulating effects of the TSH receptor antibodies.
Toxic nodular goitre

In this disorder the goitre is present for a long period of time prior to the development
of clinical symptoms. In most goitres the nodules are inactive and in some cases it is
the internodular tissue that is responsible for the goitre.
Toxic nodule
Overactive, autonomously functioning nodule. It may occur as part of generalised
nodularity or be a true toxic adenoma. The TSH levels are usually low as the
autonomously functioning thyroid tissue will exert a negative feedback effect.
Signs and symptoms

Symptoms Signs
Lethargy Tachycardia
Emotionally labile Agitation
Heat intolerance Hot, moist palms
Weight loss Exopthalmos
Excessive appetite Thyroid goitre and bruit
Palpitations Lid lag/retraction
Diagnosis
The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised).
Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH
level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies may be tested
for in the diagnosis of Graves.
Treatment
First line treatment for Graves disease is usually medical and the block and replace
regime is the favored option. Carbimazole is administered at higher doses and
thyroxine is administered orally. Patient are maintained on this regime for between 6
and 12 months. Attempts are then made to wean off medication. Where relapse then
occurs the options are between ongoing medical therapy, radioiodine or surgery.
A 23 year old lady has Graves disease that has relapsed on stopping anti thyroid,
radioiodine is offered as the next treatment by the endocrinologists. Which statement
is false?
A. Close contact with children is not permitted for up to 4 weeks

following treatment.
B. 15% of patients with opthalmopathy will see worsening of eye signs.
C. Symptomatic improvement takes 6-8 weeks
D. Up to 80% of patients will become hypothyroid.
E. None of the above.

Radio-iodine- may worsen opthalmopathy, contraindicated in pregnancy and those
wishing to concieve within 6 months.
Radioiodine vs. Surgery

Surgery Radioiodine
Symptomatic improvement within 10 days Symptomatic improvement takes up to 2
months
No effect on opthalmopathy Eye signs may worsen
Risk of damage to adjacent anatomical No risk of anatomical damage
structures
No restrictions on contact No contact with children for 4 weeks
Thyroid disease

Assessment
 History
Thyroid Tumours
 Lymphoma's
Multinodular goitre




Theme: Thyroid disease
A. Papillary carcinoma
B. Follicular carcinoma
C. Multinodular goitre
D. Parathyroid adenoma
E. Anaplastic thyroid carcinoma
F. Medullary carcinoma
G. Toxic nodule
H. Graves disease
Please select the most likely thyroid lesion for the scenario given. Each option may be
used once, more than once or not at all.
16. A 34 year old female presents with a thyroid nodule. She has a family history
of thyroid disease and both her sisters have undergone total thyroidectomies.
Her past medical history includes hypertension which has been difficult to
manage.
Medullary carcinoma
This is a typical scenario for medullary carcinoma in which a

phaeochromocytoma may also be present. It may be inherited in an autosomal
dominant fashion and affected family members may be offered prophylactic
thyroidectomy.
17. A 46 year old man is admitted to hospital with a femoral shaft fracture that
occurred suddenly whilst he was out walking his dog. On examination there is
no neurovascular deficit distal to the fracture site. He has a large firm nodule in
the left lobe of the thyroid, there is no associated lymphadenopathy.
Follicular carcinomas may metastasise haematogenously (often to bone) where

they may give rise to pathological fractures as in this case.
18. An 18 year old female presents with 3 nodules in the right lobe of the thyroid.
Clinically she is euthyroid and there is associated cervical lymphadenopathy.
She has no family history of thyroid disease.
Papillary carcinoma
Papillary thyroid cancers are the most common type of thyroid cancer and are
the more common in females (M:F=1:3). Papillary tumours are more likely to
develop lymphatic spread than follicular tumours.
Thyroid disease

Assessment
 History
Thyroid Tumours
 Lymphoma's
Multinodular goitre





A 19 year old male presents with bilateral gynaecomastia, poor vision and nipple
discharge. Which of the following blood tests is most likely to be abnormal?
A. Oestrogen
B. Testosterone
C. β HCG
D. Prolactin
E. Calcitonin
A combination of nipple discharge, gynaecomastia and poor vision may well be

associated with a prolactinoma. The poor vision results from compression of the optic
chiasm resulting in bi temporal hemianopia.
Gynaecomastia
Gynaecomastia describes an abnormal amount of breast tissue in males and is usually

caused by an increased oestrogen:androgen ratio. It is important to differentiate the
causes of galactorrhoea (due to the actions of prolactin on breast tissue) from those of
gynaecomastia
Causes of gynaecomastia
 physiological: normal in puberty
 syndromes with androgen deficiency: Kallman's, Klinefelter's
 testicular failure: e.g. Mumps
 liver disease
 testicular cancer e.g. Seminoma secreting hCG
 ectopic tumour secretion
 hyperthyroidism
 haemodialysis
 drugs: see below
Drug causes of gynaecomastia
 spironolactone (most common drug cause)

 cimetidine
 digoxin
 cannabis
 finasteride
 oestrogens, anabolic steroids
Very rare drug causes of gynaecomastia
 tricyclics
 isoniazid
 calcium channel blockers
 heroin
 busulfan
 methyldopa
Theme: Management of calcium metabolic disorders
A. No action needed
B. Intravenous fluid (0.9% N.Saline)
C. Risedronate and calcium supplements
D. Calcium supplements
E. Exploration and parathyroidectomy
F. DEXA bone scan
G. Pamidronate IV
For each scenario please select the most appropriate management plan. Each option
20. An 80 year old woman has a hip fracture. Her calcium is normal. She has
never been given a diagnosis of osteoporosis.
You answered DEXA bone scan
The correct answer is Risedronate and calcium supplements
The osteoporosis guidelines state if a postmenopausal woman has a fracture

she should be put on bisphosphonates (there is no need for a DEXA scan).
21. A 60 year old man presents with recurrent renal stones. He is found to have a
calcium of 2.72 (elevated) and a PTH of 12 (elevated).
Exploration and parathyroidectomy
This patient has primary hyperparathyroidism and nephrolithiasis, which is an

indication for parathyroidectomy.
22. An 82 year old woman from a nursing home is admitted to the orthopaedic
ward with a hip fracture. She is acutely confused and agitated. Her Calcium is
2.95 (elevated).
Intravenous fluid (0.9% N.Saline)
This patient needs rehydration due to hypercalcaemia. An intravenous

bisphosphonate is indicated if the Ca is above 3.
Hyperparathyroidism
> 0.01 emotional or
cognitive state
calcifications
Tertiary  Ca (Normal or  Metastatic
2+
Occurs as a result
(Decreased or  Pancreatitis underlying renal
Normal) disorder,
 Vitamin D hyperplasia of all 4
(Normal or glands is usually the
decreased) cause
 Alkaline
phosphatase
(Elevated)
Treatment

 Nephrolithiasis
 Age < 50 years
lower than -2.5)
 Bone pain
References

Endocrinol 2011; 2011: 251410.
Theme: Management of thyroid disease
A. Total Thyroidectomy
B. Thyroid lobectomy
C. Sub total thyroidectomy
D. Radioactive iodine
E. Carbimazole
F. Tru cut biopsy
G. Further fine needle aspiration
H. Observation
For each scenario please select the most appropriate management option. Each option
23. A 59 year old man is referred with symptoms of dysphagia. On examination he

has a large goitre and on imaging there is significant retrosternal extension and
features of a multinodular goitre.
You answered Sub total thyroidectomy
The correct answer is Total Thyroidectomy
Sub total thyroidectomy is no longer routinely undertaken in this group.
24. A 48 year old lady with thyrotoxicosis is referred to the clinic, she was poorly
controlled on carbimazole and has received orbital radiotherapy for severe
proptosis. This has improved matters but she relapsed on stopping her
carbimazole.
You answered Radioactive iodine
The correct answer is Total Thyroidectomy
Eye signs worsen with radioiodine.
25. A 23 year old lady has re attended the clinic on three occasions with a cyst in
her thyroid that refills. Cytology on each occasion is reassuring.
You answered Tru cut biopsy
The correct answer is Thyroid lobectomy
Persist refilling cysts may be associated with a well differentiated tumour and
should be removed by lobectomy.
Thyroid disease

Assessment
 History
Thyroid Tumours
 Lymphoma's
Multinodular goitre



Which of the following are not true of follicular thyroid cancer?
A. They often appear to be encapsulated.
B. Those with a Hurthle cell subtype have an excellent prognosis.
C. Haematogenous metastasis is more common than in Papillary

carcinoma.
D. The overall mortality rate is 24%.
E. Vascular invasion is seen in up to 60% of cases.

The Hurthle cell subtype have a worse prognosis.
Thyroid malignancy
Papillary carcinoma

evaluation.
thyroidectomy.

Medullary carcinoma
origin.
recurrence.
Lymphoma
 Theme: Thyroid function tests
A. Thyrotoxicosis
B. Sick euthyroid syndrome
C. Hypothyroidism
D. Poor compliance with thyroid medication
E. Hashimotos thyroiditis
F. Multinodular goitre

Please select the most likely diagnosis for the scenario given. Each option may
27. A 52 year old woman presents with an acute ischaemic right arm. She is found
to have fast atrial fibrillation. Her blood results reveal a free T4 level of 20 and
a TSH of < 0.01.
Thyrotoxicosis
The diagnosis is thyrotoxicosis. An elevated T4 and a low TSH should indicate

this diagnosis. Remember atrial fibrillation and its complications i.e acute
ischaemic limbs can be precipitated by hyperthyroid disorders.
28. A 42 year old woman presents with a goitre. On examination the goitre feels
'lumpy'. The blood results reveal a TSH of 12 and a free T4 of 2. Antithyroid
peroxidase antibodies are high.
Hashimotos thyroiditis
Hashimotos usually presents in women aged between 30- 50 years. They are
normally associated with a goitre. To differentiate from hypothyroidism, the
antithyroid peroxidase antibodies will be elevated.
29. A 55 year old man is on the intensive care unit for many months after open
aortic surgery. He is maintained on total parenteral nutrition. Clinically he is
euthyroid, but his thyroid function tests reveal a low TSH and low T4.
Sick euthyroid syndrome
Sick euthyroid syndrome is most commonly seen in chronically ill patients or

those with starvation. The thyroid function tests are often low and the patient
clinically euthyroid.

 Thyroid function tests

Theme from January 2012 exam
The interpretation of thyroid function tests is usually straightforward:
Disorder TSH Free T4

Thyrotoxicosis (e.g. Graves' Low High In T3 thyrotoxicosis the free T4
disease) will be normal
Primary hypothyroidism (primary High Low
atrophic hypothyroidism)
Secondary hypothyroidism Low Low Replacement steroid therapy is
required prior to thyroxine
Sick euthyroid syndrome* Low** Low Common in hospital inpatients
Poor compliance with thyroxine High Normal /
high
Steroid therapy Low Normal

*now referred to as non-thyroidal illness
**TSH may be normal in some cases

 Theme: Nottingham prognostic index
A. <2.5
B. <3.4
C. 3.4-5.4
D. >5.4

Please match the prognosis of patients who have undergone breast cancer
surgery to the most appropriate Nottingham Prognostic Index score. Each
option may be used once, more than once or not at all.
30. Good prognosis
You answered <2.5
The correct answer is <3.4
The Nottingham prognostic index may be used to stratify patients into various
prognostic groups (see below). An excellent prognosis is seen with a score of
<2.4. A good prognosis is usually associated with a score of <3.4.
31. Intermediate prognosis
3.4-5.4
32. Poor prognosis
>5.4

 Nottingham prognostic index

The Nottingham Prognostic Index can be used to give an indication of

survival. In this system the tumour size is weighted less heavily than other
major prognostic parameters.
Calculation of NPI
Tumour Size x 0.2 + Lymph node score(From table below)+Grade
score(From table below).

Score
1 0 1
2 1-3 2
3 >3 3

Prognosis

2.0 to 2.4 93%
2.5 to 3.4 85%
3.5 to 5.4 70%
>5.4 50%

This data was originally published in 1992. It should be emphasised that other
factors such as vascular invasion and receptor status also impact on survival
and are not included in this data and account for varying prognoses often cited
in the literature.
Reference
Galea, M.H., et al., The Nottingham Prognostic Index in primary breast
cancer. Breast Cancer Res Treat, 1992. 22(3): p. 207-19.
A 56 year old lady undergoes a mastectomy as treatment for multifocal ductal
carcinoma in situ. Two weeks post operatively she attends the clinic and complains of
a diffuse swelling at the surgical site. On examination she has a large, fluctuant area
underlying the mastectomy skin flaps. She is otherwise well. What is the most likely
cause?
A. Abscess
B. Seroma
C. Haematoma
D. Disease recurrence
E. Arteriovenous malformation
Seromas are very common after breast surgery. The exposed raw surfaces created
during the elevation of the skin flaps are a common cause. Treatment usually involves
percutaneous drainage under aseptic conditions.
Complications of breast surgery
Breast surgery may be associated with the following complications:
 Long thoracic nerve injury. This may occur during the axillary dissection and
result in winging of the scapula.
 Intercostobrachial nerve injury. These nerves traverse the axilla. When they
are divided (which they often are) the patient will notice an area of parasthesia
in the armpit.
 Injury to the thoracodorsal trunk. This nerve and vessels supply latissimus
dorsi. If they are damaged the functional effects are not too serious, the
greatest setback is that a latissimus dorsi flap cannot be used for reconstruction
purposes.
 Infections. Cellulitis of the chest wall and arm may be a major problem if
axillary nodal clearance is undertaken. Infections may run a protracted course
and require polytherapy for treatment.
 Lymphoedema. Usually complicates axillary node clearance or irradiation.
Treatment is with manual lymphatic drainage and compression sleeves.
 Seroma. This is an accumulation of fluid at the site of surgery. The fluid is
usually straw coloured and may re-accumulate despite drainage. Most will
resolve with time.
You are the specialist trainee in endocrinology clinic. The medical team have referred
a man for a parathyroidectomy who has a corrected calcium of 2.82 (elevated) and a
PTH of 11 (elevated). Which of the following is not an indication for
parathyroidectomy?
A. Nephrolithiasis
B. Reduction in bone mineral density of the femoral neck, lumbar spine,

or distal radius of more than 2.5 standard deviations below peak bone
mass
C. Age < 50 years
D. Episode of life threatening hypercalcaemia
E. None of the above
All of the situations listed are indications for parathyroidectomy. See below for more
information.
Hyperparathyroidism
> 0.01 emotional or
cognitive state
calcifications
Tertiary  Ca2+ (Normal or  Metastatic Occurs as a result
(Decreased or  Pancreatitis underlying renal
Normal) disorder,
 Vitamin D hyperplasia of all 4
(Normal or glands is usually the
decreased) cause
 Alkaline
phosphatase
(Elevated)
Treatment

 Nephrolithiasis
 Age < 50 years
lower than -2.5)
 Bone pain
References
Endocrinol 2011; 2011: 251410.
Theme: Breast disease treatment
A. Mastectomy
B. Sentinel lymph node biopsy
C. Axillary node clearance
D. Wide local excision
E. Breast lump excision biopsy
F. Image guided wide local excision
G. Radiotherapy
H. Chemotherapy
I. Excision of margins
J. Discharge to routine follow-up
Please select the most appropriate management option from the list for the scenario
given. Each option may be used once, more than once or not at all.
35. A 35 year old woman has undergone a wide local excision. The histology
shows an invasive lobular carcinoma present at 3 of the resection margins.
Cavity shavings taken at the original operation are also involved. Sentinel node
biopsy was negative.
Mastectomy
This patient has an extensive disease process and lobular cancers are notorious
for being multifocal. In this case a mastectomy is the safest next step.
36. A 56 year old woman has undergone a wide local excision and axillary node
sample. The histology shows a 2.5cm invasive ductal carcinoma grade 1 which
is completely excised. None of the axillary lymph nodes show evidence of
metastatic disease.
Radiotherapy
This woman has a good prognosis. However, irradiation of the breast is

mandatory after breast cancer has been treated using breast conserving surgery.
37. A 28 year old female presents with a painless lump in the upper outer quadrant
of her left breast. Imaging using ultrasound is indeterminate (U3). Two core
biopsies have now been performed and both show normal breast tissue (B1).
You answered Discharge to routine follow-up

The correct answer is Breast lump excision biopsy
The imaging and biopsy results are not concordant. At this stage an excision
biopsy is the safest option.
Breast cancer management
 Surgery is performed in most patients suffering from breast cancer.

 Chemotherapy may be used to downstage tumours and allow breast
conserving surgery. Hormonal therapy may also be used for the same
purposes.
 Radiotherapy is given to all patients who have undergone breast conserving
surgery.
 Patients who have undergone mastectomy may be offered a reconstructive
procedure either in conjunction with their primary resection or as a staged
procedure at a later date.
Surgical options

DCIS >4cm DCIS <4cm
Central lesions may be managed using breast conserving surgery, where an

Axillary disease
 As a minimum, all patients with invasive breast cancer should have their axilla
staged. In those who do not have overt evidence of axillary nodal involvement
this can be undertaken using sentinel lymph node biopsy.
 Patients with a positive sentinel lymph node biopsy or who have imaging and
cytological or histological evidence of axillary nodal metastasis should
undergo axillary node clearance.
 Axillary node clearance is associated with the development of lymphoedema,
increased risk of cellulitis and frozen shoulder.
Theme: Non operative treatment of breast cancer

A. Radiotherapy
B. Cytotoxic chemotherapy
C. Surveillence alone
D. Endocrine therapy using tamoxifen
E. Endocrine therapy using letrozole
F. Endocrine therapy using medroxyprogesterone acetate
Please select the most appropriate agent for the situation described. Each option may
38. A 55 year old lady has undergone a wide local excision and sentinel lymph
node biopsy for breast cancer. The histology report shows a completely
excised 1.3cm grade 1 invasive ductal carcinoma. The sentinel node contained
no evidence of metastatic disease. The tumour is oestrogen receptor negative.
Radiotherapy
Radiotherapy is routine following breast conserving surgery. Without

irradiation the local recurrence rates are approximately 40%.
39. An 88 year old lady presents with a large mass in the upper inner quadrant of
her right breast. Investigations confirm an oestrogen receptor positive, invasive
ductal carcinoma. She has declined operative treatment.
You answered Endocrine therapy using tamoxifen
The correct answer is Endocrine therapy using letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually

most will escape hormonal control. In post menopausal women oestrogens are
produced by the peripheral aromatization of androgens and aromatase
inhibitors are therefore the most popular agent in this age group.
40. A 38 year old lady has undergone a mastectomy and axillary node clearance
for invasive ductal carcinoma. The histology report shows a completely
excised 3.5cm lesion which is grade 3. Two of the axillary lymph nodes
contain metastatic disease. The tumour is oestrogen receptor negative.
Cytotoxic chemotherapy
The combination of a grade 3 tumour and axillary nodal metastasis in a young

female would attract a recommendation for chemotherapy. Some may also add
herceptin (if they are HER 2 positive).
Breast cancer treatment
Treatment Indication
Endocrine  Oestrogen receptor positive tumours
therapy  Downstaging primary lesions
 Definitive treatment in old, infirm patients
Irradiation  Wide local excision

 Large lesion, high grade or marked vascular invasion
following mastectomy
Chemotherapy  Downstaging advanced lesions to facilitate breast conserving

surgery
 Patients with grade 3 lesions or axillary nodal disease
Which of the following statements regarding papillary carcinoma of the thyroid is

false?
A. They account for the majority of thyroid carcinomas
B. Spread predominantly via the lymphatics
C. May be diagnosed using fine needle aspiration cytology
D. When viewed microscopically may demonstrate 'orphan Annie 'nuclei
E. Have a five year survival of 65% if confined to the thyroid alone
The prognosis for localised papillary carcinomas is excellent. Survival rates at 5 years
approach 90%.
Thyroid malignancy
Papillary carcinoma
evaluation.
thyroidectomy.

Medullary carcinoma
origin.
recurrence.
Lymphoma

Theme: Breast malignancy
A. Eczema of the nipple

B. Ductal carcinoma in situ
C. Mucinous carcinoma
D. Invasive ductal carcinoma
E. Invasive lobular carcinoma
F. Paget's disease of the nipple
G. Lobular carcinoma in situ.
What is the likely diagnosis for the scenario given? Each option may be used once,
more than once or not at all.
42. A 74 year old woman presents with a breast lump. On examination is has a soft
consistency. The lump is removed and sliced apart. Macroscopically there is a
grey, gelatinous surface.
Mucinous carcinoma
Mucinous carcinomas comprise 2-3% of all breast cancers. They are one of the
special type of carcinomas. These have a better prognosis that tumours of Non
Special Type (NST) and axillary nodal disease is rare in this group.
43. A 74 year old woman presents with an erythematous rash originating in the
nipple. It is spreading to the surrounding areolar area and the associated
normal tissue.
You answered Eczema of the nipple
The correct answer is Paget's disease of the nipple
Paget's is associated with DCIS or invasive carcinoma.Unlike eczema of the

nipple which predominantly affects the areolar region, Pagets will usually
affect the nipple first and then spread to the areolar area. Diagnosis is made by
punch biopsy.
44. A 53 year old woman presents with a bloody nipple discharge. On

mammography there is calcification behind the nipple areolar complex. A core
biopsy shows background benign change, but cells that show comedo necrosis
which have not breached the basement membrane.
Ductal carcinoma in situ
Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It

is has a high risk of being associated with foci of invasion.
Breast cancer

Surgical options

DCIS >4cm DCIS <4cm


parameters.
Calculation of NPI
table below).

Score
1 0 1
2 1-3 2
3 >3 3
Prognosis

2.0 to 2.4 93%
2.5 to 3.4 85%
3.5 to 5.4 70%
>5.4 50%
References
(2009), doi:10.1016/j.ejso.2009.01.008

C. Nodal Status: A. Mitotic Number B. Grade

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A 43 year old lady has recently undergone a wide local excision and sentinel lymph

E. Oestrogen receptor status

Theme from April 2012 Exam

 Commoner in the older age group

Mastectomy Wide Local Excision

Central lesions may be managed using breast conserving surgery where an

Image sourced from Wikipedia

Nottingham Prognostic Index

Lymph nodes involved Grade

Score Percentage 5 year survival

You answered Cytology of duct fluid

The correct answer is Reassure and discharge

You answered Reassure and discharge

The correct answer is Total duct excision

You answered Cytology of duct fluid

The correct answer is Microdochectomy

Causes of nipple discharge

Mammary duct  Dilatation breast ducts.

Carcinoma  Often blood stained

Intraductal papilloma  Commoner in younger patients

 Examine breast and determine whether there is mass lesion present

Management of non malignant nipple discharge

 Exclude endocrine disease

Theme: Breast disease

A. Ductal carcinoma in situ

You answered Paget's disease of the nipple

The correct answer is Inflammatory carcinoma

Inflammatory breast cancers have an aggressive nature. Dissemination occurs

You answered Lobular carcinoma in situ

The correct answer is Invasive ductal carcinoma

Invasive lobular carcinoma

This is likely to be an invasive lobular carcinoma, mainly due to the multifocal

 Commoner in the older age group

Mastectomy Wide Local Excision

Central lesions may be managed using breast conserving surgery where an

Image sourced from Wikipedia

Nottingham Prognostic Index

Lymph nodes involved Grade

Score Percentage 5 year survival

E. Giant cell tumour

 Due to impaired lymphatic drainage in the presence of normal capillary

Primary  Congenital < 1 year: sporadic, Milroy's disease

Secondary  Bacterial/fungal/parasitic infection (filariasis)

Indications for surgery

 Marked disability or deformity from limb swelling

D. Familial hypocalciuric hypercalcaemia

E. Hypercalacemia associated with malignancy

Parathyroid glands and disorders of calcium metabolism

 Elevated serum Calcium > 1mg/dL above normal

Indications for surgery in secondary (renal) hyperparathyroidism:

2. MacKenzie-Feder J et al. Primary Hyperparathyroidism: An Overview. Int J

A. Simple mastectomy alone

Wide local excision and sentinel lymph node biopsy

Simple mastectomy alone

Multifocal DCIS is usually treated with a simple mastectomy. A wide local

You answered Radical mastectomy and axillary node clearance

The correct answer is Simple mastectomy and axillary node clearance

A combination of established axillary disease and multifocal invasive lesions

Breast cancer management

 Surgery is performed in most patients suffering from breast cancer.

Mastectomy Wide Local Excision

Central lesions may be managed using breast conserving surgery, where an