* Standard recommendation for any abdominal hernia is elective repair to prevent future strangulation. * 9month old baby girl is brought in with an umbilical hernia. Defect is 1cm in diameter and contents are freely reducible. Specifically, umbilical hernias below age 2 may close on their own, so this is a case where elective repair is not warranted.
* 18yo man has a routine physical exam for college admission and a right inguinal hernia is found. External inguinal ring is about 2.5cm in diameter, hernia bulge is felt in scrotum when he strains. Answer is elective repair.
* 72yo farmer is forced by his insurance company to have a physical exam to be issued a life insurance policy. He has been healthy his whole life and never been to the doctor. Physical exam shows large left inguinal hernia reaching down to hernia. Bowel sounds can be heard over it. Hernia is not reducible, he use to be able to push it back, but not for the last 10-20years. Normally, if the hernia is irreducible it should be an emergency surgery. In this case, the answer is elective surgery.
* The presence of a sliding hiatal hernia is not an indication for surgery. Parahiatal esophageal hernias are though. --- General Surgery: Breast Disease
* Answer for management should always begin with ruling out cancer, meaning only via the pathologist. Most important predictor for cancer of the breast and thus treatment is age. So non-invasive tests for younger patients. As a note, mammography is a screening tool, not a diagnostic tool, but it can help find other areas for scrutiny if we find a breast mass. FNA (fine needle aspiration) is not considered invasive. Contraindications for mammogram include age below 20 years and lactating woman. Pregnancy is not a contraindication.
* 18yo woman has firm rubbery mass in left breast, moves easily with palpation. Answer is fibroadenoma. Answer for management is FNA or sonogram, then removal at the option of the patient.
* 14yo girl has a firm moveable rubbery mass in left breast felt one year ago, now is 6cm in diameter. Answer is giant juvenile fibroadenoma. Answer for management is recommend removal.
* 27yo immigrant from Mexico has a 12x10x7cm mass in her left breast. Present for 7 years, slowly growing to current size. Mass is firm, rubbery, completely movable, not attached to chest wall or overlying skin, no palpable axillary nodes. Answer is cystosarcoma phyllodes. It is benign with malignant potential to sarcoma. FNA is not sufficient. Answer requires tissue diagnosis (biopsy) and management is removal.
* 35yo woman has 10-year history of tenderness in both breasts related to menstrual cycle, multiple lumps in both breasts that come and go. She has firm, round, 2cm mass that has not gone away for six weeks. Answer is fibrocystic disease (mammary dysplasia) and next step is mammogram. However, there is a mass that hasn’t gone away. Answer now is likely cyst but could be a tumor/cancer, so we do a mammogram then aspiration of the suspected cyst, not an FNA, if fluid is clear then we’re done. If we aspirate and get bloody fluid then it goes to cytology. If we aspirate and the mass stays or comes back in a day or two, we do tissue sampling via biopsy.
* 34yo woman has been having bloody discharge from the right nipple on and off for several months. Answer is intraductal papilloma, a small 2-3mm benign tumor in young woman, but it could be carcinoma. So, answer for next step is mammogram. If lesion found, we biopsy and proceed. Intraductal papilloma is likely not seen so we would then do a galactogram or retroareolar surgical exploration then remove that segment of the breast to stop discharge. * 26yo lactating mother has cracks in the nipple and develops a fluctuating red, hot tender mass with a fever and leukocytosis. Answer is breast abscess, seen only in lactating women. Answer for next step is not mammogram since patient is lactating. Answer is operating room incision and drainage and a biopsy of the wall of the abscess to rule out infected cancer.
* 49yo woman has firm 2cm mass in breast present for two months. Answer for next step is mammogram to confirm sole area, then do tissue sampling. We could begin with an FNA, but if negative you still need the core biopsy. * 34yo woman in her fifth month of pregnancy has 3cm firm ill-defined mass in her right breast that has been growing for three months. Answer for next step is mammogram (shield fetus) and tissue sampling. Only two limitations are no chemo in first trimester of pregnancy and no radiation therapy to the breast at any point. It is not necessary to terminate the pregnancy as it does not increase cancer growth.
* 69yo woman has 4cm hard mass in right breast with ill-defined borders, movable from the chest wall but not moveable within the breast, skin overlying the mass is retracted and has orange-peel appearance. Answer is cancer of the breast.
* 69yo woman has 4cm hard mass in right breast with ill-defined borders, movable from the chest wall but not moveable within the breast, nipple became retracted six months ago (desmoplastic reaction, but note some women have retracted nipples all their life). Answer for next step is mammogram, tissue sample, and don’t stop until you have generous tissue for testing.
* 72yo woman has red swollen breast, skin over the area looks like orange peel, she is not particularly tender and unsure if the area is hot or not, no fever, no leukocytosis. Answer is inflammatory cancer of the breast. Next step is mammogram, tissue sampling (skin would have cancer cells too).
* 62yo woman has eczematoid lesion in the areola for three months, has not gone away with a variety of skin products. Answer is Paget disease, breast cancer. Answer for next step is mammogram and biopsy.
* 42yo woman hits her breast with a broom handle while doing housework. She noticed a lump in the area at that time and one week later it is still there. 3cm hard mass deep in breast and superficial overlying ecchymosis. History
of trauma does not exclude the history of cancer. She could have hit her breast, felt the area, and then felt a lump that was originally there. Answer for next step is mammogram and then tissue sampling.
* 58yo woman discovers a mass in her right axilla, discrete hard moveable 2cm mass, breast physical exam is negative, no enlarged nodes elsewhere. If she were 22yo with other nodes in neck then you’d think lymphoma. Answer in this case is breast cancer, metastatic to the axilla. Primary is too small to palpate, which is why mammography is important. Answer for next step is mammography and biopsy of axillary node.
* 60yo woman has routine screening mammogram, radiologist reports irregular area of increased density with fine microcalcifications not present two years ago in previous mammogram. Answer for next step is radiologically- guided core biopsies.
* 44yo woman has 2cm palpable mass in upper outer quadrant of right breast. Core biopsy shows infiltrating ductal carcinoma (most common). Mass is freely moveable, breast is of normal size. No nodes, mammogram shows no other lesions. Answer for management for small cancer in large breast, far away from nipple/areola, then lumpectomy with axillary sampling and radiation to remaining breast that was operated on. Next option if small breast, or near nipple, then modified radical mastectomy with axillary sampling (not dissection) via sentinel node biopsy, meaning injection of radioactive substance then sampling of the first node. Negative palpation of the axilla has at best 50% accuracy.
* 62yo woman has a 4cm hard mass under the nipple and areola in her smallish left breast. Core biopsy diagnosis infiltrating ductal carcinoma, no other lesions on mammogram, no axillary nodes. Answer for management is modified radical mastectomy. No need for post-op radiation.
* 44yo woman has 2cm palpable mass in the upper outer quadrant of the right breast, core biopsy shows lobular cancer of the breast (or medullary cancer). Note lobular cancer has high incidence of bilaterality, but not high enough to required a bilateral mammogram. Management for these is the same as infiltrating ductal.
* 44yo woman has 2cm palpable mass in the upper outer quadrant of the right breast, core biopsy shows
inflammatory cancer of the breast. In this case, answer is do radiation and chemotherapy first, then attempt surgical resection.
* 52yo woman has suspicious area on mammogram, multiple radiologically guided biopsies show infiltrating ductal carcinoma in situ. In situ meaning not capable of metastasis here, so we don’t need to go to the axillary nodes. One answer for management is simple mastectomy as there is high risk of recurrence. Another answer is lumpectomy and radiation therapy, like the infiltrating ductal carcinoma.
* 30yo woman in the seventh month of pregnancy has 2cm mass in breast, core biopsy shows infiltrating ductal carcinoma. Answer for next step is lumpectomy or modified radical mastectomy. However, if we do lumpectomy then the radiation must wait until after the pregnancy.
* 44yo woman shows up in the ED because she is bleeding from the breast, examination shows huge fungating breast mass occupying the entire right breast and firmly attached to chest wall, patient says it has only been there for two weeks, relative says it has been there for at least two years. Tragic case of neglect and denial. Answer is breast cancer. Answer for next step is biopsy. Answer for management is chemotherapy and radiation, even though it is clearly inoperable.
* 37yo woman has lumpectomy and axillary dissection for 3cm infiltrating ductal carcinoma, pathologist notes clear margins and metastatic cancer in four of seventeen axillary nodes. Answer is cancer with systemic disease. Answer for management is systemic treatment, general rule is if patient has positive axillary nodes then we do systemic therapy, if pre-menopausal we do chemotherapy, if post-menopausal we do hormonal therapy (tamoxifen), and chemo therapy for any distant metastasis. Answer in this case is chemotherapy.
* 66yo woman has a modified radical mastectomy for infiltrating ductal carcinoma, pathology reports 4cm mass with seven of twenty-two nodes positive for metastasis, tumor is estrogen and progesterone positive. Answer is tamoxifen.
* 61yo woman has lumpectomy and axillary dissection for infiltrating ductal carcinoma of the breast, 7 of 22 nodes are positive for metastasis, liver and bone metastasis are found. Answer is chemotherapy.
* 44yo woman complains bitterly of severe headaches for several weeks that have not responded to OTC meds. She is two years post-op for modified radical mastectomy for T3N2M0 cancer of the breast with several courses of post- op chemotherapy but she discontinued because of the side effects. Answer for next step is CT scan of head, likely showing brain metastasis. Resect if they are resectable, else treat some other way. For TNM classification, just know T is for size from 0-4, N is nodal metastasis from 0-2, and M is metastasis either 0 or 1.
* 39yo woman completed her last course of post-op adjuvant chemotherapy for breast cancer. Comes to clinic with constant back pain for three weeks, tender to palpation over well-circumscribed areas in thoracic and lumber spine. Assume bony metastasis, typically to pedicle of the vertebra. Answer for next step is not x-ray, it is radionuclide
bone scan. Bone scan is most specific but not sensitive, so negative rules out, but if positive then we need x-rays to rule-out other things that light-up the bone scan, like arthritis or old fracture.
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