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404 Section II / General Surgery

What is the Whipple triad o 1. Hypoglycemia (Glc 50)


pancreatic insulinoma? 2. Symptoms of hypoglycemia: mental
status changes/vasomotor instability
3. Relief of symptoms with administration
of glucose

What is the most common islet Insulinoma


cell tumor?

What pancreatic tumor is Somatostatinoma (inhibits gallbladder


associated with gallstone contraction)
ormation?

What is the triad ound with 1. Gallstones


pancreatic somatostatinoma 2. Diabetes
tumor? 3. Steatorrhea

What are the two classic 1. Diabetes


ndings with pancreatic 2. Dermatitis/rash (necrotizing migratory
glucagonoma tumors? erythema)

Chapter 56 Breast

ANATOMY OF THE BREAST AND AXILLA


Name the boundaries o the
axilla or dissection:
Superior boundary Axillary vein

Posterior boundary Long thoracic nerve

Lateral boundary Latissimus dorsi muscle

Medial boundary Lateral to, deep to, or medial to pectoral


minor muscle, depending on level of nodes
taken

What our nerves must the 1. Long thoracic nerve


surgeon be aware o during an 2. oracodorsal nerve
axillary dissection? 3. Medial pectoral nerve
4. Lateral pectoral nerve
Chapter 56 / Breast 405

Describe the location o these


nerves and the muscle each
innervates:
Long thoracic nerve Courses along lateral chest wall in
midaxillary line on serratus anterior
muscle; innervates serratus anterior muscle

oracodorsal nerve Courses lateral to long thoracic nerve


on latissimus dorsi muscle; innervates
latissimus dorsi muscle

Medial pectoral nerve Runs lateral to or through the pectoral


minor muscle, actually lateral to the lateral
pectoral nerve; innervates the pectoral
minor and pectoral major muscles

Lateral pectoral nerve Runs medial to the medial pectoral nerve


(names describe orientation from the
brachial plexus!); innervates the
pectoral major

Identi y the nerves in the axilla 1. T oracodorsal nerve


on the illustration below: 2. Long thoracic nerve
3. Medial pectoral nerve
4. Lateral pectoral nerve
5. Axillary vein

5 1 3
2

What is the name o the “Winged scapula”


de ormity i you cut the long
thoracic nerve in this area?

What is the name o the Intercostobrachial nerve


CUTANEOUS nerve that
crosses the axilla in a transverse
ashion? (Many surgeons try to
preserve this nerve)
406 Section II / General Surgery

What is the name o the large Axillary vein


vein that marks the upper limit
o the axilla?

What is the lymphatic drainage Lateral: axillary lymph nodes


o the breast? Medial: parasternal nodes that run with
internal mammary artery

What are the levels o axillary Level I (low): lateral to pectoral minor
lymph nodes? Level II (middle): deep to pectoral minor
Level III (high): medial to pectoral minor
In breast cancer, a higher level of
involvement has a worse prognosis, but
the level of involvement is less
important than the number of positive
III
nodes (T ink: Levels I, II, and III are in
the same inferior–superior anatomic
I order as the Le Fort facial fractures and
II the trauma neck zones; I dare you to
forget!)

Caro tid
III III
II III
II
I II I
I
Ne c k zo ne s Le Fo rte Axillary
frac ture lymph no de s

What are Rotter’s nodes? Nodes between the pectoralis major and
minor muscles; not usually removed
unless they are enlarged or feel suspicious
intraoperatively

What are the suspensory breast Cooper’s ligaments


ligaments called?

What is the mammary “milk Embryological line from shoulder to thigh


line”? where “supernumerary” breast
areolar and/or nipples can be found
Chapter 56 / Breast 407

What is the “tail o Spence”? “ ail” of breast tissue that tapers into the
axilla

Which hormone is mainly Prolactin


responsible or breast milk
production?

BREAST CANCER
What is the incidence o breast 12%li etime risk
cancer?

What percentage o women 75%!


with breast cancer have no
known risk actor?

What percentage o all breast 2%


cancers occur in women younger
than 30 years?

What percentage o all breast 33%


cancers occur in women older
than 70 years?

What are the major breast BRCA1 and BRCA2 (easily remembered:
cancer susceptibility genes? BR BReast and CA CAncer)

What option exists to decrease Prophylactic bilateral mastectomy


the risk o breast cancer in
women with BRCA?

What is the most common Failure to diagnose a breast carcinoma


motivation or medicolegal
cases involving the breast?

What is the “TRIAD OF 1. Age 45 years


ERROR” or misdiagnosed 2. Self-diagnosed mass
breast cancer? 3. Negative mammogram
Note: 75% of cases of MISDIAGNOSED
breast cancer have these three
characteristics
408 Section II / General Surgery

What are the history risk “NAACP”:


actors or breast cancer? Nulliparity
Age at menarche (younger than
13 years)
Age at menopause (older than 55 years)
Cancer of the breast (in self or family)
Pregnancy with rst child ( 30 years)

What are physical/anatomic “CHAFED LIPS”:


risk actors or breast cancer? Cancer in the breast (3% synchronous
contralateral cancer)
Hyperplasia (moderate/ orid)
(2 risk)
Atypical hyperplasia (4 )
Female (100 male risk)
Elderly
DCIS

LCIS
Inherited genes (BRCA I and II)
Papilloma (1.5 )
Sclerosing adenosis (1.5 )

What is the relative risk o 1–1.5


hormone replacement
therapy?

Is “run o the mill” brocystic No


disease a risk actor or breast
cancer?

What are the possible No symptoms


symptoms o breast cancer? Mass in the breast
Pain (most are painless)
Nipple discharge
Local edema
Nipple retraction
Dimple
Nipple rash

Why does skin retraction umor involvement of Cooper’s ligaments


occur? and subsequent traction on ligaments pull
skin inward
Chapter 56 / Breast 409

What are the signs o breast Mass (1 cm is usually the smallest lesion
cancer? that can be palpated on examination)
Dimple
Nipple rash
Edema
Axillary/supraclavicular nodes

What is the most common site Approximately one half of cancers develop
o breast cancer? in the upper outer quadrants

What are the di erent types o In ltrating ductal carcinoma ( 75%)


invasive breast cancer? Medullary carcinoma ( 15%)
In ltrating lobular carcinoma ( 5%)
ubular carcinoma ( 2%)
Mucinous carcinoma (colloid) ( 1%)
In ammatory breast cancer ( 1%)

What is the most common type In ltrating ductal carcinoma


o breast cancer?

What is the di erential Fibrocystic disease of the breast


diagnosis? Fibroadenoma
Intraductal papilloma
Duct ectasia
Fat necrosis
Abscess
Radial scar
Simple cyst

Describe the appearance o Peau d’orange (orange peel)


the edema o the dermis in
inf ammatory carcinoma o
the breast.

What are the screening


recommendations or breast
cancer:
Breast exam Self-exam of breasts monthly
recommendations? Ages 20 to 40 years: breast exam every
2 to 3 years by a physician
40 years: annual breast exam by physician

Mammograms? Mammogram every year or every other


year a er age 40
410 Section II / General Surgery

When is the best time or breast 1 week a er menstrual period


sel -exams?

Why is mammography a more Breast tissue undergoes fatty replacement


use ul diagnostic tool in older with age, making masses more visible;
women than in younger? younger women have more brous tissue,
which makes mammograms harder to
interpret

What are the radiographic tests Mammography and breast ultrasound,


or breast cancer? MRI

What is the classic picture o Spiculated mass


breast cancer on mammogram?

Which option is the best initial Breast ultrasound


test to evaluate a breast mass
in a woman younger than 30
years?

What are the methods or Fine needle aspiration (FNA), core biopsy
obtaining tissue or pathologic (larger needle core sample), mammotome
examination? stereotactic biopsy, and open biopsy, which
can be incisional (cutting a piece of the
mass) or excisional (cutting out the entire
mass)

What are the indications Persistent mass a er aspiration


or biopsy? Solid mass
Blood in cyst aspirate
Suspicious lesion by mammography/
ultrasound/MRI
Bloody nipple discharge
Ulcer or dermatitis of nipple
Patient’s concern of persistent breast
abnormality
Chapter 56 / Breast 411

What is the process or Stereotactic (mammotome) biopsy or


per orming a biopsy when a needle localization biopsy
nonpalpable mass is seen on
mammogram?

What is a needle loc biopsy Needle localization by radiologist, followed


(NLB)? by biopsy; removed breast tissue must be
checked by mammogram to ensure all of
the suspicious lesion has been excised

What is a mammotome biopsy? Mammogram-guided computerized


stereotatic core biopsies

What is obtained rst, the Mammogram is obtained rst; otherwise,


mammogram or the biopsy? tissue extraction (core or open) may
alter the mammographic ndings ( ne
needle aspiration may be done prior to
the mammogram because the ne needle
usually will not a ect the mammographic
ndings)

What would be suspicious Mass, microcalci cations, stellate/


mammographic ndings? spiculated mass

What is a “radial scar” seen on Spiculated mass with central lucency,


mammogram? microcalci cations

What tumor is associated with ubular carcinoma; thus, biopsy is


a radial scar? indicated

What is the “workup” or a 1. Clinical breast exam


breast mass? 2. Mammogram or breast ultrasound
3. Fine needle aspiration, core biopsy, or
open biopsy

How do you proceed i the Aspirate it with a needle


mass appears to be a cyst?

Is the f uid rom a breast cyst Not routinely; bloody uid should be sent
sent or cytology? for cytology

When do you proceed to open 1. In the case of a second cyst recurrence


biopsy or a breast cyst? 2. Bloody uid in the cyst
3. Palpable mass a er aspiration
412 Section II / General Surgery

What is the preoperative Bilateral mammogram (cancer in one


staging workup in a patient breast is a risk factor for cancer in the
with breast cancer? contralateral breast!)
CXR (to check for lung metastasis)
LF s (to check for liver metastasis)
Serum calcium level, alkaline phosphatase
(if these tests indicate bone metastasis/
“bone pain,” proceed to bone scan)
Other tests, depending on signs/
symptoms (e.g., head C if patient has
focal neurologic de cit, to look for
brain metastasis)

What hormone receptors must Estrogen and progesterone receptors—


be checked or in the biopsy this is key or determining adjuvant
specimen? treatment; this information must be
obtained on all specimens (including ne
needle aspirates)

What staging system is used or TMN: Tumor/Metastases/Nodes (AJCC)


breast cancer?

Describe the staging (simpli ed):


Stage I umor 2 cm in diameter without
metastases, no nodes

Stage IIA umor 2 cm in diameter with mobile


axillary nodes or
umor 2 to 5 cm in diameter, no nodes

Stage IIB umor 2 to 5 cm in diameter with mobile


axillary nodes or
umor 5 cm with no nodes

Stage IIIA umor 5 cm with mobile axillary


nodes or
Any size tumor with xed axillary nodes,
no metastases

Stage IIIB Peau d’orange (skin edema) or


Chest wall invasion/ xation or
In ammatory cancer or
Breast skin ulceration or
Breast skin satellite metastases or
Any tumor and ipsilateral internal
mammary lymph nodes
Chapter 56 / Breast 413

Stage IIIC Any size tumor, no distant mets


POSI IVE: supraclavicular, infraclavicular,
or internal mammary lymph nodes

Stage IV Distant metastases (including ipsilateral


supraclavicular nodes)

What are the sites o Lymph nodes (most common)


metastases? Lung/pleura
Liver
Bones
Brain

What are the major treatments Modi ed radical mastectomy


o breast cancer? Lumpectomy and radiation sentinel
lymph node dissection
(Both treatments either postop
chemotherapy/tamoxifen)

What are the indications Stage IIIA


or radiation therapy a er a Stage IIIB
modi ed radical mastectomy? Pectoral muscle/fascia invasion
Positive internal mammary LN
Positive surgical margins
4 positive axillary LNs postmenopausal

What breast carcinomas are Stage I and stage II (tumors 5 cm)


candidates or lumpectomy and
radiation (breast-conserving
therapy)?

What approach may allow a NEOadjuvant chemotherapy—if the


patient with stage IIIA cancer preop chemo shrinks the tumor
to have breast-conserving
surgery?

What is the treatment o Chemotherapy rst! T en o en followed


inf ammatory carcinoma o by radiation, mastectomy, or both
the breast?

What is a “lumpectomy and Lumpectomy (segmental mastectomy:


radiation”? removal of a part of the breast); axillary
node dissection; and a course of radiation
therapy a er operation, over a period of
several weeks
414 Section II / General Surgery

What is the major absolute Pregnancy


contraindication to
lumpectomy and radiation?

What are other Previous radiation to the chest


contraindications to Positive margins
lumpectomy and radiation? Collagen vascular disease
(e.g., scleroderma)
Extensive DCIS (o en seen as di use
microcalci cation)
Relative contraindications:
Lesion that cannot be seen on the
mammograms (i.e., early recurrence
will be missed on follow-up
mammograms)
Very small breast (no cosmetic
advantage)

What is a modi ed radical Breast, axillary nodes (level II, I),


mastectomy? and nipple–areolar complex are
removed
Pectoralis major and minor muscles
are not removed (Auchincloss
modi cation)
Drains are placed to drain lymph
uid

Where are the drains placed 1. Axilla


with an MRM? 2. Chest wall (breast bed)

When should the drains be 30 cc/day drainage


removed?

What are the potential Ipsilateral arm lymphedema, infection,


complications a er a modi ed injury to nerves, skin ap necrosis,
radical mastectomy? hematoma/seroma, phantom breast
syndrome

During an axillary dissection, NO, because the nerves (long thoracic/


should the patient be thoracodorsal) are stimulated with
paralyzed? resultant muscle contraction to help
identify them
Chapter 56 / Breast 415

How can the long thoracic Nerves can be stimulated with a forceps,
and thoracodorsal nerves be which results in contraction of the
identi ed during an axillary latissimus dorsi (thoracodorsal nerve) or
dissection? anterior serratus (long thoracic nerve)

When do you remove the When there is 30 cc of drainage per day,


drains a er an axillary or on POD #14 (whichever comes rst)
dissection?

What is a sentinel node biopsy? Instead of removing all the axillary


lymph nodes, the primary draining or
“sentinel” lymph node is removed

How is the sentinel lymph node Inject blue dye and/or technetium-labeled
ound? sulfur colloid (best results with both)

What ollows a positive sentinel Removal of the rest of the axillary lymph
node biopsy? nodes

What is now considered the Sentinel lymph node dissection


standard o care or lymph
node evaluation in women with
T1 or T2 tumors (stages I and
IIA) and clinically negative
axillary lymph nodes?

What do you do with Open needle loc biopsy as many will have
a mammotome biopsy DCIS or invasive cancer
that returns as “atypical
hyperplasia”?

How does tamoxi en work? It binds estrogen receptors

What is the treatment or “Salvage” mastectomy


local recurrence in breast a er
lumpectomy and radiation?

Can tamoxi en prevent breast Yes. In the Breast Cancer Prevention


cancer? rial of 13,000 women at increased risk
of developing breast cancer, tamoxifen
reduced risk by 50% across all ages

What are common options or RAM ap, implant, latissimus dorsi ap


breast reconstruction?
416 Section II / General Surgery

What is a TRAM f ap? Transverse Rectus Abdominis


Myocutaneous ap

What are side e ects o Endometrial cancer (2.5 relative risk),


tamoxi en? DV , pulmonary embolus, cataracts, hot
ashes, mood swings

In high-risk women, is there Yes, tamoxifen for 5 years will lower


a way to reduce the risk o the risk by up to 50%, but, with an
developing breast cancer? increased risk of endometrial cancer and
clots, it must be an individual patient
determination

Give the common adjuvant


therapy or the ollowing
patients with breast cancer.
( ese are rough guidelines;
check or current uidelines, as
they are always changing.)
(ER estrogen receptor):
Premenopausal, node , Chemotherapy
ER

Premenopausal, node , Chemotherapy and tamoxifen


ER
Chapter 56 / Breast 417

Premenopausal, node , amoxifen and/or chemotherapy


ER

Postmenopausal, node , amoxifen, ± chemotherapy


ER

Postmenopausal, node , Chemotherapy, ± tamoxifen


ER

What type o chemotherapy is (AC ) Adriamycin/cyclophosphamide


usually used or breast cancer? then paclitaxel OR docetaxel and
cyclophosphamide

Chemotherapy or high-risk High risk: 2 cm


tumors with negative lymph 1 cm in size and ER/PR negative
nodes should be considered. Lymphatic/vascular invasion
What makes a tumor “HIGH Nuclear grade (high)
RISK”? S phase (high)
HER-2

Adjuvant erapy or HER2 rastuzumab (Anti HER2 antibody) side


tumors? e ect CH F

DCIS
What does DCIS stand or? Ductal Carcinoma In Situ

No rmal duc t Duc tal c arc ino ma


in s itu

What is DCIS also known as? Intraductal carcinoma

Describe DCIS Cancer cells in the duct without invasion


(In situ: Cells do not penetrate the
basement membrane)

What are the signs/symptoms? Usually none; usually nonpalpable


418 Section II / General Surgery

What are the mammographic Microcalci cations


ndings?

How is the diagnosis made? Core or open biopsy

What is the most aggressive Comedo


histologic type?

What is the risk o lymph node 2% (usually when microinvasion is seen)


metastasis with DCIS?

What is the major risk with Subsequent development of in ltrating


DCIS? ductal carcinoma in the same breast

What is the treatment or DCIS


in the ollowing cases:
Tumor 1 cm (low grade)? Remove with 1 cm margins and XR

Tumor 1 cm? Perform lumpectomy with 1 cm margins


and radiation or total mastectomy (no
axillary dissection)

What is a total (simple) Removal of the breast and nipple without


mastectomy? removal of the axillary nodes (always
remove nodes with invasive cancer)

When must a simple Di use breast involvement (e.g., di use


mastectomy be per ormed microcalci cations), 1 cm and
or DCIS? contraindication to radiation

What is the role o axillary No role in true DCIS (i.e., without


node dissection with DCIS? microinvasion); some perform a sentinel
lymph node dissection for high-grade DCIS

What is adjuvant Rx or DCIS? 1. amoxifen if ER positive


2. Postlumpectomy XR

What is the role o tamoxi en amoxifen for 5 years will lower the risk
in DCIS? up to 50%, but with increased risk of
endometrial cancer and clots; it must be an
individual patient determination

What is a memory aid or the Cancer arises in the same breast as DCIS
breast in which DCIS breast (T ink: DCIS Directly in same breast)
cancer arises?
Chapter 56 / Breast 419

LCIS
What is LCIS? Lobular Carcinoma In Situ (carcinoma
cells in the lobules of the breast without
invasion)

Lo bular
No rmal c arc ino ma
lo bule in s itu

What are the signs/ T ere are none


symptoms?

What are the mammographic T ere are none


ndings?

How is the diagnosis made? LCIS is found incidentally on biopsy

What is the major risk? Carcinoma of either breast

Which breast is most at risk Equal risk in both breasts! (T ink of LCIS
or developing an invasive as a risk marker for future development of
carcinoma? cancer in either breast)

What percentage o women 30% in the 20 years a er diagnosis of


with LCIS develop an invasive LCIS!
breast carcinoma?

What type o invasive breast Most commonly, in ltrating ductal


cancer do patients with LCIS carcinoma, with equal distribution in the
develop? contralateral and ipsilateral breasts

What medication may lower amoxifen for 5 years will lower the risk
the risk o developing breast up to 50%, but with an increased risk of
cancer in LCIS? endometrial cancer and clots; it must be an
individual patient determination
420 Section II / General Surgery

What is the treatment o LCIS? Close follow-up (or bilateral simple


mastectomy in high-risk patients)

What is the major di erence in LCIS cancer develops in either breast;


the subsequent development DCIS cancer develops in the ipsilateral
o invasive breast cancer with breast
DCIS and LCIS?

How do you remember which T ink: LCIS Liberally in either breast


breast is at risk or invasive
cancers in patients with LCIS?

MISCELLANEOUS
What is the most common Intraductal papilloma
cause o bloody nipple
discharge in a young woman?

What is the most common Fibroadenoma


breast tumor in patients
younger than 30 years?

What is Paget’s disease o the Scaling rash/dermatitis of the nipple


breast? caused by invasion of skin by cells from a
ductal carcinoma

What are the common options Saline implant


or breast reconstruction a er RAM ap
a mastectomy?

MALE BREAST CANCER


What is the incidence o breast 1% of all breast cancer cases (1/150)
cancer in men?

What is the average age at 65 years of age


diagnosis?

What are the risk actors? Increased estrogen


Radiation
Gynecomastia from increased estrogen
Estrogen therapy
Klinefelter’s syndrome (XXY)
BRCA2 carriers
Chapter 56 / Breast 421

Is benign gynecomastia a risk No


actor or male breast cancer?

What type o breast cancer do Nearly 100% of cases are ductal carcinoma
men develop? (men do not usually have breast lobules)

What are the signs/symptoms Breast mass (most are painless), breast skin
o breast cancer in men? changes (ulcers, retraction), and nipple
discharge (usually blood or a blood-tinged
discharge)

What is the most common Painless breast mass


presentation?

How is breast cancer in men Biopsy and mammogram


diagnosed?

What is the treatment? 1. Mastectomy


2. Sentinel LN dissection of clinically
negative axilla
3. Axillary dissection if clinically positive
axillary LN

BENIGN BREAST DISEASE


What is the most common Fibrocystic disease
cause o green, straw- colored,
or brown nipple discharge?

What is the most common Fat necrosis


cause o breast mass a er
breast trauma?

What is Mondor’s disease? T rombophlebitis of super cial breast veins

What must be ruled out with Prolactinoma (check pregnancy test and
spontaneous galactorrhea prolactin level)
( / amenorrhea)?

CYSTOSARCOMA PHYLLODES
What is it? Mesenchymal tumor arising from breast
lobular tissue; most are benign (Note:
“sarcoma” is a misnomer, as the vast
majority are benign; 1% of breast cancers)
422 Section II / General Surgery

What is the usual age o the 35–55 years (usually older than the patient
patient with this tumor? with broadenoma)

What are the signs/ Mobile, smooth breast mass that resembles
symptoms? a broadenoma on exam, mammogram/
ultrasound ndings

How is it diagnosed? T rough core biopsy or excision

What is the treatment? If benign, wide local excision; if malignant,


simple total mastectomy

What is the role o axillary Only if clinically palpable axillary nodes,


dissection with cystosarcoma as the malignant form rarely spreads to
phyllodes tumor? nodes (most common site of metastasis is
the lung)

Is there a role or chemotherapy Consider chemotherapy if large tumor


with cystosarcoma phyllodes? 5 cm and “stromal overgrowth”

FIBROADENOMA
What is it? Benign tumor of the breast consisting of
stromal overgrowth, collagen arranged in
“swirls”

What is the clinical Solid, mobile, well-circumscribed round


presentation o a breast mass, usually 40 years of age
broadenoma?

How is broadenoma Negative needle aspiration looking for


diagnosed? uid; ultrasound; core biopsy

What is the treatment? Surgical resection for large or growing


lesions; small broadenomas can be
observed closely

What is this tumor’s claim Most common breast tumor in women


to ame? 30 years

FIBROCYSTIC DISEASE
What is it? Common benign breast condition
consisting of brous (rubbery) and cystic
changes in the breast
Chapter 56 / Breast 423

What are the signs/symptoms? Breast pain or tenderness that varies with
the menstrual cycle; cysts; and brous
(“nodular”) fullness

How is it diagnosed? T rough breast exam, history, and aspirated


cysts (usually straw-colored or green uid)

What is the treatment or Stop ca eine


symptomatic brocystic Pain medications (NSAIDs)
disease? Vitamin E, evening primrose oil (danazol
and OCP as last resort)

What is done i the patient has Needle drainage: If aspirate is bloody or a


a breast cyst? palpable mass remains a er aspiration,
an open biopsy is performed
If the aspirate is straw colored or green,
the patient is followed closely; then,
if there is recurrence, a second
aspiration is performed
Re-recurrence usually requires open biopsy

MASTITIS
What is it? Super cial infection of the breast (cellulitis)

In what circumstance does it Breast-feeding


most o en occur?

What bacteria are most Staphylococcus aureus


commonly the cause?

How is mastitis treated? Stop breast-feeding and use a breast pump


instead; apply heat; administer antibiotics

Why must the patient with o make sure that she does not have
mastitis have close ollow-up? in ammatory breast cancer!

BREAST ABSCESS
What are the causes? Mammary ductal ectasia (stenosis of breast
duct) and mastitis

What is the most common Nursing Staphylococcus aureus


bacteria? Nonlactating mixed infection
424 Section II / General Surgery

What is the treatment o breast Antibiotics (e.g., dicloxacillin)


abscess? Needle or open drainage with cultures taken
Resection of involved ducts if recurrent
Breast pump if breast-feeding

What is lactational mastitis? Infection of the breast during breast-


feeding—most commonly caused by
S. aureus; treat with antibiotics and follow
for abscess formation

What must be ruled out with a Breast cancer!


breast abscess in a nonlactating
woman?

MALE GYNECOMASTIA
What is it? Enlargement of the male breast

What are the causes? Medications


Illicit drugs (marijuana)
Liver failure
Increased estrogen
Decreased testosterone

What is the major di erential Male breast cancer


diagnosis in the older patient?

What is the treatment? Stop or change medications; correct


underlying cause if there is a hormonal
imbalance; and perform biopsy or
subcutaneous mastectomy (i.e., leave
nipple) if refractory to conservative
measures and time

Chapter 57 Endocrine
ADRENAL GLAND
Anatomy
Where is the drainage o the Le renal vein
lef adrenal vein?

Where is the drainage o the Inferior vena cava (IVC)


right adrenal vein?
Chapter 57 / Endocrine 425

Normal Adrenal Physiology


What is CRH? Corticotropin-Releasing Hormone: released
from anterior hypothalamus and causes
release of AC H from anterior pituitary

What is ACTH? AdrenoCorticoTropic Hormone: released


normally by anterior pituitary, which in
turn causes adrenal gland to release cortisol

What eeds back to inhibit Cortisol


ACTH secretion?

Cushing’s Syndrome
What is Cushing’s syndrome? Excessive cortisol production (T ink:
Cushing’s Cortisol

What is the most common cause? Iatrogenic (i.e., prescribed prednisone)

What is the second most Cushing’s disease (most common


common cause? noniatrogenic cause)

What is Cushing’s disease? Cushing’s syndrome caused by excess


production of AC H by anterior pituitary

Ac ne
I’m we ak
Hirs utis m
I’m de pre s s e d Buffalo
hump

Hig h blo o d
pre s s ure

Purple
s triatio ns 200
Trunc al
o be s ity

Eas y
bruis ing

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