Breast and Endocrine Surgery

Match each patient's clinical presentation and breast pathology findings with the most appropriate surgical or overall management strategy.

A $31$-year-old man comes to the physician for evaluation of a painless neck mass he noticed while shaving two weeks ago. For the past four months, he has experienced episodic, severe headaches accompanied by profound sweating and palpitations, which he attributed to work-related stress. His blood pressure is $172/98$ mm Hg, and his pulse is $108$/min. Physical examination reveals a $2.5$-cm, firm, mobile, non-tender mass in the right anterior neck. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of $6.2$ $\mu$ U/mL (normal: $0.4$–$4.0$ $\mu$ U/mL) and a free thyroxine (T4) level of $1.1$ ng/dL (normal: $0.9$–$2.4$ ng/dL). An ultrasound of the neck demonstrates a $2.3$-cm solid, hypoechoic nodule with microcalcifications in the right thyroid lobe. Fine-needle aspiration biopsy of the nodule reveals clusters of spindle-shaped cells with pleomorphic nuclei and extracellular deposits that demonstrate apple-green birefringence under polarized light after Congo red staining. Which of the following is the most appropriate next step in the management of this patient?

A $32$-year-old woman, gravida $2$, para $1$, at $18$ weeks gestation presents to the clinic after noticing a new mass in her right breast $2$ weeks ago. She reports no breast pain, skin changes, or nipple discharge. She has no personal or family history of breast cancer. Vital signs are within normal limits. Physical examination reveals a $3$-cm, firm, non-tender, and relatively fixed mass in the upper outer quadrant of the right breast. There is no overlying erythema, warmth, or peau d'orange. Palpation of the right axilla reveals a firm, mobile $1.5$-cm lymph node. The left breast and axilla are normal. Which of the following is the most appropriate next step in the evaluation of this patient's breast mass?

Match each patient presentation of hyperparathyroidism with the most appropriate surgical management strategy.

A 35-year-old woman presents to the clinic after noticing a lump in her neck while applying lotion. She denies weight changes, palpitations, heat or cold intolerance, or changes in bowel habits. She has no family history of thyroid disease or head and neck irradiation. Vital signs are within normal limits. Physical examination reveals a 1.5-cm, firm, mobile nodule in the left lobe of the thyroid gland. There is no cervical lymphadenopathy. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.8 µU/mL (normal: 0.4–4.0 µU/mL) and a free T4 of 1.2 ng/dL (normal: 0.9–2.4 ng/dL). An ultrasound of the neck demonstrates a 1.6-cm solid, hypoechoic nodule with irregular margins and microcalcifications in the left thyroid lobe. Which of the following is the most appropriate next step in management?

A $38$-year-old man presents to the clinic complaining of episodic headaches, excessive sweating, and a feeling of a rapid heart rate. His blood pressure in the clinic is $172/105 \text{ mmHg}$. He reports that these "spells" have been occurring once or twice a week for the past $3$ months. Physical examination is otherwise unremarkable. Laboratory evaluation reveals a serum potassium of $4.2 \text{ mEq/L}$ and fasting blood glucose of $115 \text{ mg/dL}$. A $24$-hour urine collection shows fractionated metanephrines that are $4$ times the upper limit of normal. Contrast-enhanced CT of the abdomen reveals a $4.5 \text{ cm}$ well-circumscribed, lipid-poor mass in the right adrenal gland. The patient is scheduled to undergo a laparoscopic right adrenalectomy in $3$ weeks. Which of the following is the most appropriate preoperative pharmacological sequence to prevent perioperative complications?

Match the following thyroid nodule presentations and cytology findings with the most appropriate initial surgical or medical management.

During a routine wellness examination, a $54$-year-old woman is found to have an asymmetric thyroid gland. She reports feeling generally well, though she notes a mild increase in anxiety and occasional loose stools over the past two months. Her heart rate is $92/min$ and blood pressure is $128/78$ $mmHg$. Physical examination reveals a non-tender, mobile, $2.8$ cm nodule in the right lobe of the thyroid gland. There is no palpable cervical lymphadenopathy. Laboratory testing reveals:

Thyroid-stimulating hormone (TSH): $0.04$ $\mu U/mL$ (normal: $0.4-4.0$ $\mu U/mL$)
Free thyroxine (T4): $2.1$ $ng/dL$ (normal: $0.9-1.7$ $ng/dL$)

A neck ultrasound confirms a $2.8$ cm solid, hypoechoic right-sided thyroid nodule with increased internal vascularity. Which of the following is the most appropriate next step in the management of this patient?

A $42$-year-old woman is evaluated in the hospital on postoperative day $2$ following a total thyroidectomy for a large toxic multinodular goiter. Her current medications include levothyroxine. She reports new-onset tingling around her mouth and in the fingertips of both hands. She also mentions mild nausea and states she has not had a bowel movement since before the surgery. She has no difficulty breathing or voice changes. Vital signs are temperature $38.0^{\circ}\text{C}$ ($100.4^{\circ}\text{F}$), blood pressure $122/78\text{ mmHg}$, heart rate $84/\text{min}$, and respiratory rate $14/\text{min}$. Physical examination reveals twitching of the ipsilateral facial muscles when the area just anterior to the earlobe is tapped. The surgical incision is clean, dry, and intact without erythema or fluctuance. The lungs are clear to auscultation. The abdomen is soft and non-distended with hypoactive bowel sounds.

Laboratory results are as follows:

Which of the following is the most appropriate next step in the management of this patient?

A $51$-year-old male is evaluated in the surgical oncology clinic for a newly discovered neck mass. Two weeks ago, he underwent a carotid duplex ultrasound as part of a workup for transient visual changes, which incidentally revealed a $2.6\text{ cm}$ solid nodule in the right thyroid lobe. The patient reports an $8$-month history of progressive fatigue, decreased libido, and feeling cold constantly. He has no personal or family history of head and neck irradiation or thyroid malignancy. His blood pressure is $108/68\text{ mmHg}$ and pulse is $54\text{/min}$. Physical examination shows a firm, non-tender nodule palpable in the right anterior neck. No cervical lymphadenopathy is present. Testicular examination reveals bilaterally small, soft testes. Laboratory studies show:

Thyroid-stimulating hormone (TSH): $0.12\text{ \mu U/mL}$ (normal: $0.4-4.0\text{ \mu U/mL}$)
Free thyroxine (T4): $0.5\text{ ng/dL}$ (normal: $0.9-1.7\text{ ng/dL}$)

Which of the following is the most appropriate next step in the diagnostic evaluation of this patient's thyroid nodule?

Match each clinical presentation of an adrenal mass with the most appropriate specific perioperative or surgical management step.

A 42-year-old woman comes to the clinic for evaluation of a newly noticed lump in her anterior neck. She reports no pain, hoarseness, dysphagia, or recent changes in her weight. Physical examination reveals a non-tender, 2.5-cm, mobile nodule in the right lobe of the thyroid gland. A neck ultrasound confirms a 2.5-cm solid, hypoechoic nodule in the right thyroid lobe with regular margins. Laboratory studies show a serum thyroid-stimulating hormone (TSH) level of 0.1 mU/L (normal: 0.4-4.0 mU/L). Which of the following is the most appropriate next step in management?

A $46$-year-old woman is referred to the endocrine surgery clinic for evaluation of a neck mass discovered $3$ weeks ago. She reports a $6$-month history of severe fatigue, generalized weakness, and a $5$ kg ($11$ lb) unintended weight gain. She has not seen a physician in several years. Her medical history is notable for a complicated vaginal delivery $15$ years ago that required multiple blood transfusions and an extended intensive care unit stay. She currently takes no medications. Vital signs are blood pressure $92/58$ mmHg and heart rate $62$/min. Physical examination reveals a $3.5$ cm, firm, mobile nodule in the right thyroid lobe. She is noted to have pale skin and sparse axillary and pubic hair.

Laboratory studies show:
Thyroid-stimulating hormone (TSH): $0.2$ $\mu$ U/mL (Normal: $0.5$ - $5.0$ $\mu$ U/mL)
Free thyroxine (T4): $0.5$ ng/dL (Normal: $0.9$ - $1.7$ ng/dL)

An ultrasound-guided fine-needle aspiration of the nodule reveals findings suspicious for papillary thyroid carcinoma (Bethesda Category V). The surgical team is planning to schedule a total thyroidectomy. Which of the following is the most appropriate next step in management prior to surgical intervention?

A 45-year-old woman is referred to the surgical clinic for evaluation of a neck mass she noticed while applying lotion. She reports a 4-kg (8.8-lb) weight loss over the past 3 months despite an increased appetite, as well as occasional palpitations. She has no personal or family history of head and neck irradiation or endocrine malignancies. Vital signs are within normal limits except for a heart rate of 102/min. Physical examination reveals a 3-cm, firm, non-tender, mobile nodule in the right thyroid lobe. Laboratory studies show:

Thyroid-stimulating hormone (TSH): 0.05 µU/mL (normal: 0.4–4.0 µU/mL)
Free thyroxine (T4): 2.4 ng/dL (normal: 0.8–1.8 ng/dL)

A dedicated neck ultrasound demonstrates a 3.2-cm solid, markedly hypoechoic nodule in the right lobe with irregular margins and internal microcalcifications. No abnormal cervical lymph nodes are identified. Which of the following is the most appropriate next step in management?

Match each clinical presentation of an endocrine lesion with its most appropriate diagnostic or surgical management step.

A 62-year-old woman is evaluated in the endocrine surgery clinic for a $3.5\text{ cm}$ right-sided thyroid nodule that she noticed while swallowing. She reports mild localized discomfort but no voice changes. She also notes a 6-month history of profound fatigue, intermittent dizziness upon standing, and decreased appetite. Her medical history is unremarkable, and she takes no medications.

Physical examination reveals a firm, mobile, non-tender nodule in the right thyroid lobe. Her blood pressure is $92/58\text{ mmHg}$ while supine and $80/50\text{ mmHg}$ upon standing. Her heart rate is $82/\text{min}$.

Neck ultrasound demonstrates a solid, hypoechoic $3.5\text{ cm}$ nodule with microcalcifications in the right lobe. Fine-needle aspiration biopsy reveals a follicular neoplasm (Bethesda category IV), and a diagnostic right thyroid lobectomy is planned.

Which of the following is the most appropriate next step in the management of this patient?

Match the following common breast pathologies with their classic clinical presentations.

Match the following clinical presentations of patients with adrenal masses or adrenal dysfunction to the most appropriate next step in management or surgical intervention.

A $38$-year-old man presents to the office to evaluate a newly discovered mass in his neck. He first noticed it while shaving two weeks ago. The patient reports no dysphagia, hoarseness, palpitations, headaches, or diaphoresis. He was adopted as a child and his family medical history is unknown. He takes no medications. Vital signs include a blood pressure of $152/94$ mm Hg and a heart rate of $88$/min. Physical examination reveals a $2.7$-cm, firm, non-tender nodule in the right lobe of the thyroid gland. No cervical lymphadenopathy is appreciated. Laboratory testing shows a serum thyroid-stimulating hormone level of $1.8$ $\mu\text{U}/\text{mL}$ (normal: $0.4$-$4.0$ $\mu\text{U}/\text{mL}$). An ultrasound of the neck confirms a solid, hypoechoic right thyroid nodule with irregular margins. A subsequent fine-needle aspiration biopsy of the nodule yields cytology consistent with medullary thyroid carcinoma. Which of the following is the most appropriate next step in the management of this patient?

A 31-year-old female patient schedules an appointment to discuss persistent bilateral breast secretions that began four months ago. She also reports feeling unusually sluggish, experiencing new-onset constipation, and gaining $5\text{ kg}$ ($11\text{ lbs}$) during this timeframe. Her menstrual periods, previously predictable, are now occurring every 45 to 50 days. A home pregnancy test taken last week was negative. She is not taking any over-the-counter or prescription medications. Vital signs show a heart rate of $58\text{/min}$ and a blood pressure of $110/70\text{ mmHg}$. On physical examination, there are no palpable masses, skin dimpling, or axillary lymphadenopathy. Gentle expression yields a milky white fluid from both nipples.

Laboratory testing reveals the following:

Based on these findings, which of the following is the most appropriate next step in management?