Match each clinical presentation with the most appropriate next step in surgical managemen… — USMLE Step 2 CK

Match each clinical presentation with the most appropriate next step in surgical management.

A $35$ -year-old woman with a $2$ -cm breast mass; core biopsy demonstrates pleomorphic lobular carcinoma in situ.Surgical excision with negative margins
A $42$ -year-old woman with a $1.5$ -cm thyroid nodule; fine-needle aspiration reveals medullary thyroid carcinoma.Total thyroidectomy with central neck dissection
A $50$ -year-old man with symptomatic hypercalcemia, elevated parathyroid hormone, and negative localization on both ultrasound and sestamibi scan.Bilateral four-gland neck exploration
A $45$ -year-old woman with a biochemically silent $5.5$ -cm adrenal mass exhibiting $35$ Hounsfield units on non-contrast CT.Surgical resection (adrenalectomy)

Answer

The presentations map to their specific surgical interventions based on pathological variants (pleomorphic LCIS requires clear margins), predictable metastatic patterns (MTC requires central neck dissection), imaging limitations (non-localized primary hyperparathyroidism requires bilateral exploration), and malignant potential (large, dense adrenal masses require resection).

Each surgical approach is tailored to the specific oncologic or anatomic challenges of the disease: margin-negative excision for aggressive pleomorphic LCIS, prophylactic central node dissection for medullary thyroid cancer, bilateral exploration when hyperparathyroidism cannot be localized, and prophylactic adrenalectomy for large adrenal masses at high risk for primary carcinoma.

Step-by-Step Solution

Analyze the breast mass presentation.

Identified pleomorphic LCIS.

Pleomorphic LCIS requires surgical excision with negative margins, distinguishing it from classic LCIS, which is typically managed with observation or chemoprevention.

Analyze the thyroid nodule presentation.

Identified medullary thyroid carcinoma.

Due to frequent early micrometastases, MTC is uniquely treated with both total thyroidectomy and prophylactic central neck dissection.

Analyze the hypercalcemia presentation.

Identified primary hyperparathyroidism with non-localizing preoperative imaging.

Without a localized adenoma on imaging, targeted approaches are contraindicated, necessitating bilateral exploration to locate all parathyroid glands.

Analyze the adrenal mass presentation.

Identified a large, dense adrenal incidentaloma without biochemical activity.

Masses

>4

cm or with high Hounsfield units are at high risk for adrenocortical carcinoma and require adrenalectomy regardless of functional status.

Key Concept

Surgical Indications in Breast and Endocrine Pathologies

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