Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

2019 International Clinical Practice Guidelines for the Treatment and Prophylaxis Of Venous Thromboembolism In Patients With Cancer

• Initial treatment of established VTE – International Advisory Panel ranking (8.18 out of 9)
  • Low-molecular-weight heparin (LMWH):
    • Is recommended for the initial treatment of established VTE in patients with cancer:
      • When creatinine clearance is ≥ 30 mL per min (grade 1B)
    • LMWH:
      • Is easier to use than unfractionated heparin
    • A regimen of LMWH:
      • Taken once per day:
        • Is recommended, unless a twice-per-day regimen is required:
          • Because of patient characteristics (eg, fragile patients who are at risk of hemorrhage)
  • For patients who do not have a high risk of gastrointestinal or genitourinary bleeding:
    • A regimen of rivaroxaban (in the first 10 days) or edoxaban (started after at least 5 days of parenteral anticoagulation):
      • Can also be used for the initial treatment of established VTE:
        • In patients with cancer when creatinine clearance is ≥ 30 mL/min (grade 1B)
  • Unfractionated heparin:
    • Can also be used for the initial treatment of established VTE in patients with cancer:
      • When LMWH or direct oral anticoagulants are contraindicated, or not available (grade 2C)
  • Fondaparinux can also be used for the initial treatment of established VTE:
    • For patients with cancer (grade 2D)
    • Fondaparinux is easier to use than unfractionated heparin
  • Thrombolysis in patients with cancer with established VTE can only be considered on a case-by-case basis:
    • With specific attention paid to contraindications, especially bleeding risk eg, brain metastasis (guidance, based on evidence of very low quality and the high bleeding risk of thrombolytic therapy)
    • An expert opinion is recommended before using thrombolytics, and the procedure should be done in centers with health-care practitioners who have appropriate expertise
  • In the initial treatment of VTE:
    • Inferior vena cava filters may be considered when:
      • Anticoagulant treatment is contraindicated or
      • In the case of pulmonary embolism
      • When recurrence occurs under optimal anticoagulation
    • Periodic reassessment of contraindications for anticoagulation is recommended, and anticoagulation should be resumed when safe (guidance, based on evidence of very low quality and an unknown balance between desirable and undesirable effects)
• Early maintenance (up to 6 months) and long term (beyond 6 months) – International Advisory Panel ranking (8.09 out of 9):
  • LMWHs are preferred over vitamin K antagonists:
    • For the treatment of VTE in patients with cancer:
      • When creatinine clearance is ≥ 30 mL/min (grade 1A)
    • Daily subcutaneous injection can represent a burden for patients
  • Direct oral anticoagulants:
    • Are recommended for patients with cancer:
      • When creatinine clearance is ≥ 30 mL/min in the absence of strong drug-to-drug interactions or gastrointestinal absorption impairment (grade 1A)
    • Use caution in patients with:
      • Gastrointestinal tract malignancies, especially upper gastrointestinal tract malignancies:
        • As the available data show increased risk of gastrointestinal tract bleeding with:
          • Edoxaban and rivaroxaban
    • Data for other direct oral anticoagulants are needed as it is not clear whether other direct oral anticoagulants will have the same risk profile
  • LMWH or direct oral anticoagulants should be used for:
    • A minimum of 6 months to treat established VTE in patients with cancer (grade 1A)
    • After 6 months:
      • Termination or continuation of anticoagulation (LMWH, direct oral anticoagulants, or vitamin K antagonists):
        • Should be based on individual evaluation of the benefit–risk ratio, tolerability, drug availability, patient preference, and cancer activity (guidance in the absence of data)
• Treatment of VTE recurrence in patients with cancer under anticoagulation – International Advisory Panel ranking (8.0 out of 9):
  • In the event of VTE recurrence, three options can be considered:
    • Increase LMWH by 20% to 25%
    • Switch to direct oral anticoagulants:
      • For direct oral anticoagulants:
        • Switch to LMWH
    • For vitamin K antagonists:
      • Switch to LMWH or direct oral anticoagulants (guidance based on evidence of very low quality and an unknown balance between desirable and undesirable effects)
  • Effect of therapy should be monitored:
    • By improvement of symptoms
• Treatment of established catheter-related thrombosis – International Advisory Panel ranking (8.19 out of 9):
  • For the treatment of symptomatic catheter-related thrombosis in patients with cancer:
    • Anticoagulant treatment is recommended for a minimum of 3 months and as long as the central venous catheter is in place
    • In this setting:
      • LMWHs are suggested and direct comparisons between LMWHs, direct oral anticoagulants, and vitamin K antagonists have not been made (guidance)
  • In patients with cancer with catheter-related thrombosis:
    • The central venous catheter can be kept in place:
      • If it is functional, well positioned, and not infected:
        • With a good resolution of symptoms under close surveillance while anticoagulation therapy is administered
  • No standard approach in terms of duration of anticoagulation is established (guidance)
• Reference:
  • 2019 international clinical practice guidelines for the treatment and prophylaxis of venous thromboembolism in patients with cancer. Crossref DOI link: https://doi.org/10.1016/S1470-2045(19)30336-5. Published: 2019-10. Update policy: https://doi.org/10.1016/ELSEVIER_CM_POLICY

#Arrangoiz #Surgeon #CancerSurgeon @Teacher #HeadandNeckSurgeon #ThyroidSurgeon #ParathyroidSurgeon #CASO #Miami #CenterforAdvancedSurgicalOncology #DVT #Thromboembolism

• Demographics:
  • Advanced age
  • Overweight or obesity (particularly in postmenopausal women)
  • White race or Ashkenazi Jewish descent
• Medical history:
  • BRCA1 or BRCA2 mutation
  • First-degree relative with breast or ovarian cancer
  • History of atypical hyperplasia or lobular carcinoma in situ
  • One prior breast biopsy (regardless of results)
  • Personal history of breast or ovarian cancer
• Medications and diet:
  • Alcohol consumption (more than one drink per day)
  • Current or prior use of hormone therapy or oral contraceptives
• Reproductive history: o Menarche before 12 years of age o Menopause after 55 years of age o Nulliparity or age older than 35 years at first delivery • Other: o High breast density on mammography o Prior thoracic radiation exposure

• Sentinel lymph node biopsy (SLNB):
  • Is the standard of care in patients with early stage, clinically node negative breast cancer
• Compared to axillary lymph node dissection (ALND),:
  • SLNB has lower morbidity, including a:
    • Lower risk of musculoskeletal limitations and lymphedema
• In general, SLNB can be performed with the use of:
  • Blue dye
  • Technetium-99 (99mTc), or
  • Dual agents
• The role of SLNB in pregnancy is not clearly defined:
  • Recently updated American Society of Clinical Oncology (ASCO) Guidelines:
    • Upholds its prior recommendation that SLNB should not be performed in pregnancy:
      • The strength of the recommendation, however;
        • Is described by the ASCO expert panel to be “weak,” as it is based on ”informal consensus” rather than quality evidence.
• Several retrospective studies have described the safety of SLNB during pregnancy
  • The majority of patients in these studies underwent SLNB with 99mTc alone:
    • However, methylene blue dye was used in some patients
  • One recent retrospective review reported on 145 women with clinical node-negative disease who underwent SLNB during pregnancy:
    • The mapping agents utilized were:
      • 99mTc alone (66%), methylene blue dye alone (9.7%), dual agents (10.3%), and the remainder was unknown
    • Sentinel lymph nodes were identified in 99.3% of patients, with excellent gestational outcomes
  • No neonatal adverse events related to the SLNB procedure were reported
• Models of fetal radiation exposure have demonstrated that the use of 99mTc for SLNB:
  • Leads to a negligible dose to the fetus of 0.014 mGy or less:
    • Whereas risk of fetal malformation is associated with levels > 100 mGy
  • Lower doses of exposure can be achieved using a 1-day protocol rather than a 2-day protocol
• The use of lymphazurin dye is not recommended:
  • Due to the 1% to 2% risk of anaphylaxis
• Historically, the use of direct intra-amniotic injection of methylene blue dye for identification of ruptured membranes led to significant neonatal complications:
  • Recent pharmacokinetic data indicate that the absorption of methylene blue dye used during SLNB is minimal
  • Although the use of methylene blue dye for SLNB has been described, the data are limited in comparison to that of 99mTc
• Thus, with respect to axillary staging, the risks and benefits of ALND vs. SLNB must be discussed with the patient prior to surgery

• References
  • Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994;220(3):391-398.
  • Lyman GH, Somerfield MR, Bosserman LD, Perkins CL, Weaver DL, Giuliano AE. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology Clinical Practice Guideline Update.J Clin Oncol. 2017;35(5):561-564.
  • Han SN, Amant F, Cardonick EH, et al. Axillary staging for breast cancer during pregnancy: feasibility and safety of sentinel lymph node biopsy. Breast Cancer Res Treat. 2018;168(2):551-557.
  • Gropper AB, Calvillo KZ, Dominici L, et al. Sentinel lymph node biopsy in pregnant women with breast cancer. Ann Surg Oncol. 2014;21(8):2506-2511.
  • Gentilini O, Cremonesi M, Toesca A et al. Sentinel lymph node biopsy in pregnant patients with breast cancer. Eur J Nucl Med Mol Imaging. 2010;37(1):78-83.
  • Pandit-Taskar N, Dauer LT, Montgomery L et al. Organ and fetal absorbed dose estimates from 99mTc-sulfur colloid lymphoscintigraphy and sentinel node localization in breast cancer patients. J Nucl Med. 2006;47(7):1202-1208.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #CASO #CenterforAdvancedSurgicalOncologist #BreastCancer #BreastCancerandPregnancy

👉The vascular anatomy of the abdominal wall is divided into three zones based on the origin of the blood suppl

• 𝗭𝗼𝗻𝗲 1 is the central upper abdomen
  • Superiorly it receives blood supply from the descending superior epigastric artery, a branch of the internal mammary artery
  • Inferiorly it is supplied by the ascending inferior epigastric artery, a branch of the external iliac artery
  • As the superior and inferior epigastric arteries run posterior to the rectus abdominis muscle, they supply musculocutaneous perforating vessels (the so-called periumbilical perforator vessels) to the overlying tissues
  • The superior and inferior epigastric arteries converge in the supraumbilical region
• 𝗭𝗼𝗻𝗲 2 encompasses the suprapubic area below the arcuate line
  • The area is supplied medially by the superficial and deep branches of the inferior epigastric artery
  • Laterally, blood supply comes from the superficial circumflex iliac artery as a branch of the external iliac
• 𝗭𝗼𝗻𝗲 3 is the area superior the arcuate line and lateral to the linea semilunaris
  • It is perfused superiorly by the musculophrenic artery as a lateral branch of the internal mammary artery
  • Inferiority by the deep circumflex iliac artery
• When evaluating a patient who requires ventral herniorrhaphy, the blood supply to each zone should be considered as it may be comprised by prior surgical incisions (such as a panniculectomy or paramedian incision) or prior surgical procedure (such as epigastric ligation or abdominal aortic aneurysm repair)
• 𝗖𝗹𝗶𝗻𝗶𝗰𝗮𝗹 𝗶𝗺𝗼𝗽𝗿𝘁𝗮𝗻𝗰𝗲:
  • 𝗭𝗼𝗻𝗲𝘀 1 and 3:
    • Kocher and Chevron incisions generally divide the right and potentially left superior epigastric artery and must be considered in patients who have had open cholecystectomy, liver resection, or liver transplantation
    • In addition, patients who have had the internal mammary artery harvested for coronary bypass grafting, mediastinal dissection, or mediastinal chest tubes can disrupt the internal mammary, superior epigastric artery, or musculophrenic blood supply to Zones 1 and 3
  • 𝗭𝗼𝗻𝗲 2:
    • Blood supply is at risk with prior paramedian, Mcburney, Rockey-Davis, and Pfannenstiel incisions
    • Additionally the periumbilical region is a watershed area with tenuous blood supply in patients with large umbilical hernias and previous midline scars
    • Failure to excise compromised skin or scar can lead to wound breakdown and surgical site infections

𝗥𝗲𝗳:SAGES manual of hernia surgery, 2019.
By: Hesham Wageh

#Arrangoiz #Surgeon #Teacher

• Inflammatory breast cancer (IBC):
  • Is a clinical diagnosis characterized by:
    • The rapid progression of an enlarged breast with skin changes including:
      • Redness
      • Edema
      • Peau d’orange
  • As mentioned previously IBC is a clinical diagnosis defined by the American Joint Committee on Cancer as a:
    •  “Diffuse erythema and edema involving approximately a third or more of the skin of the breast” and is staged cT4d
  • A punch biopsy of the skin:
    • Demonstrates tumor emboli within dermal lymphatics:
      • Approximately 75% of the time
    • A negative skin biopsy does NOT preclude the diagnosis, as it is clinical
  • The appearance may lead to:
    • Misdiagnosis of mastitis or breast cellulitis
  • The rapid evolution of symptoms (within 3 to 6 months):
    • Distinguishes IBC from a locally advanced breast cancer with associated edema
  • IBC is rare:
    • It presents in 2% to 4% of breast cancer patients:
      • Although the reported annual incidence has been increasing.
  • The tumor biology is disproportionately:
    • ER negative and HER2 amplified, compared with non-IBC
  • Patients should be evaluated in a multidisciplinary setting for trimodal therapy
  • Treatment should be initiated with:
    • Neoadjuvant chemotherapy, followed by aggressive local therapy
  • The majority of patients with IBC present with clinical lymph node involvement:
    • Sentinel lymph node biopsy is not reliable in IBC:
      • Due to blockage of dermal lymphatics:
        • Thus axillary dissection should be performed
  • Following neoadjuvant chemotherapy:
    • Modified radical mastectomy is the appropriate surgery:
      • Skin should not be spared so as not to leave behind residual disease
    • Immediate reconstruction should be avoided
  • Patients should receive post-mastectomy radiation:
    • To the skin, chest wall, and regional lymph nodes following surgery:
      • To optimize local control
  • Survival in IBC has improved with trimodal therapy:
    • A recent analysis of Surveillance, Epidemiology, and End Results data evaluated 10,197 patients with non-metastatic IBC between 1998 and 2010:
      • Patients who underwent trimodal therapy had improved 5- and 10-year survival (55.4% and 37.3%) over those that did not receive all three modalities
      • Survival was lowest at 10 years (16.5%) for patients who underwent surgery alone
  • Staging scans, including a CT chest / abdomen/ pelvis, PET scan, and / or bone scan:
    • Should be completed prior to initiating treatment
  • Inflammatory breast cancer is a clinical stage T4d:
    • And the most fatal form of breast cancer:
      • Accounting for 7% of all breast cancer deaths:
        • Real-world observational data have demonstrated that inflammatory breast cancer has significantly worse survival compared to other non-metastatic locally advanced and metastatic non-inflammatory breast cancers
      • Despite this, 5-year survival of IBC patients has increased from:
        • 40% to 50% in the 1990’s to almost 70% in 2008
  • Recent national and international guidelines for IBC recommend:
    • Full staging (PET / CT preferred over CT chest / abdomen / pelvis + bone scan) and bilateral breast and axillary nodal imaging, followed by neoadjuvant systemic therapy, modified radical mastectomy (including level I and II lymph node dissection), and radiation
    • Adjuvant targeted therapy and hormonal therapy should be considered in appropriate cases
    • Notably, lumpectomy is contraindicated
    • Breast reconstruction should be delayed
    • Multi-modal therapy for IBC has resulted in the best overall survival rates
  • For HER2-negative breast cancers:
    • Preoperative chemotherapy regimens should include:
      • Sequential doxorubicin and cyclophosphamide followed by a taxane:
        • To achieve the highest pathologic complete response rate
  • For HER2-positive breast cancers:
    • Chemotherapy should be used with dual anti-HER2-directed therapy with pertuzumab and trastuzumab:
      • To achieve the best pathologic complete response rate
• References
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Available with login at: https://subscriptions.nccn.org.
  • Fouad TM, Barrera AMG, Reuben JM, Lucci A, Woodward WA, Stauder MC, et al. Inflammatory breast cancer: a proposed conceptual shift in the UICC-AJCC TNM staging system. Lancet Oncol. 2017;18(4):e228-e232.
  • Ueno NT, Espinosa Fernandez JR, Cristofanilli M, Overmoyer B, Rea D, Berdichevski F, et al. International consensus on the clinical management of inflammatory breast cancer from the Morgan Welch Inflammatory Breast Cancer Research Program 10th Anniversary Conference. J Cancer. 2018;9(8):1437-1447.
  • Rueth NM, Lin HY, Bedrosian I, Shaitelman SF, Ueno NT, Shen Y, et al. Underuse of trimodality treatment affects survival for patients with inflammatory breast cancer: an analysis of treatment and survival trends from the National Cancer Database. J Clin Oncol. 2014;32(19):2018-2024.
  • Amin MB, Edge S, Greene F, et al., eds. AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017
  • Hance KW, Anderson WF, Devesa SS, Young HA, Levine PH. Trends in inflammatory breast carcinoma incidence and survival: the surveillance, epidemiology, and end results program at the National Cancer Institute. J Natl Cancer Inst 2005;97(13):966-975.
  • NCCN clinical practice guidelines in oncology. National Comprehensive Cancer Network. http://www.nccn.org/professionals/physician_gls/f_guidelines.asp. Accessed August 25, 2019.
  • Menta A, Fouad TM, Lucci A, et al. Inflammatory breast cancer: what to know about this unique, aggressive breast cancer. Surg Clin North Am. 2018;98(4):787-800.
  • Rueth NM, Lin HY, Bedrosian I, et al: Underuse of trimodality treatment affects survival for patients with inflammatory breast cancer: an analysis of treatment and survival trends from the National Cancer Database. J Clin Oncol. 2014;32(19):2018-2024.

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #InflammatoryBreastCancer #CASO #CenterforAdvancedSurgicalOncology

• The decision to undergo CPM:
  • Is intensely personal
  • Frequently driven by:
    • A shifting balance between perceived future breast cancer risk
    • Anxiety over annual screening and potential future diagnostic procedures
    • The unknown physical, emotional, and cosmetic outcomes of the surgery
• Long-term outcomes for women who have undergone CPM:
  • Report that 86% to 90% of respondents:
    • Were satisfied with the decision to undergo prophylactic surgery
  • With 20 years of follow-up:
    • More than 90 % of women definitely or probably would choose to undergo CPM again:
      • However, many of these same women report dissatisfaction with areas such as:
        • Body image, chronic pain, problems with implants, and sexual changes even though they noted overall satisfaction with their decision making
  • In a study of 296 women who participated in the National Prophylactic Mastectomy Registry and provided detailed responses to a survey evaluating their outcomes with CPM:
    • Only 6 % expressed regrets with the decision:
      • But of these women 39 % reported poor cosmetic outcomes and 22 % reported a reduced sense of sexuality:
        • Studies with longer follow-up had outcome data only on a proportion of the initial cohort, introducing possible bias between responders and nonresponders, limiting the strength of the evidence.
• Few studies have examined quality of life between CPM and non-CPM patients:
  • One study, approximately 10 years ago:
    • Showed no difference in quality of life between patients undergoing CPM and those undergoing unilateral mastectomy or lumpectomy
  • In a study from Sweden:
    • No differences in overall health-related quality of life were identified up to two years post surgery in 60 women undergoing (delayed) CPM
• Summary:
  • While 80% to 90 % of women report satisfaction with their decision to undergo CPM:
    • 20% to 30 % of these women report postsurgical dissatisfaction with cosmesis, body image, and sexuality
  • Studies show that CPM does not affect overall quality of life parameters
  • Women should be counseled on the potential long-term outcomes of CPM on body image and sexuality
• References:
  • Roberts A, Habibi M, Frick KD. Cost-effectiveness of contralateral prophylactic mastectomy for prevention of contralateral breast cancer. Ann Surg Oncol. 2014;21:2209–2217. doi: 10.1245/s10434-014-3588-7.
  • Frost MH, Slezak JM, Tran NV, et al. Satisfaction after contralateral prophylactic mastectomy: the significance of mastectomy type, reconstructive complications, and body appearance. J Clin Oncol. 2005;23:7849–7856. doi: 10.1200/JCO.2005.09.233
  • Rosenberg SM, Sepucha K, Ruddy KJ, et al. Local therapy decision-making and contralateral prophylactic mastectomy in young women with early-stage breast cancer. Ann Surg Oncol. 2015;22:3809–3815. doi: 10.1245/s10434-015-4572-6
  • Geiger AM, West CN, Nekhlyudov L, et al. Contentment with quality of life among breast cancer survivors with and without contralateral prophylactic mastectomy. J Clin Oncol. 2006;24:1350–1356. doi: 10.1200/JCO.2005.01.9901
  • Frost MH, Hoskin TL, Hartmann LC, Degnim AC, Johnson JL, Boughey JC. Contralateral prophylactic mastectomy: long-term consistency of satisfaction and adverse effects and the significance of informed decision-making, quality of life, and personality traits. Ann Surg Oncol. 2011;18:3110–3116. doi: 10.1245/s10434-011-1917-7
  • Altschuler A, Nekhlyudov L, Rolnick SJ, et al. Positive, negative, and disparate–women’s differing long-term psychosocial experiences of bilateral or contralateral prophylactic mastectomy. Breast J. 2008;14:25–32. doi: 10.1111/j.1524-4741.2007.00521.x

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #ProphylacticMastectomy #CASO #Miami #CenterforAdvancedSurgicalOncology

• Nipple discharge is a relatively frequent event in females:
  • Being the third most common breast symptom prompting medical care:
    • After breast pain and breast palpable mass
• Over 80% of females will develop an episode of nipple discharge during their fertile life:
  • Which can be categorized as:
    • Lactational
    • Physiological
    • Pathological 
      • According to the clinical history and the characteristics of the discharge
• Lactational nipple discharge:
  • Is considered as a normal milk production
  • It is expected during pregnancy and lactation:
    • May persist for up to one-year post-partum or after cessation of breastfeeding
• When a milky nipple discharge:
  • Occurs in females without recent history of pregnancy or lactation:
    • It is called galactorrhea:
      • Commonly involves bilateral multiple ducts
      • This is the result of an inappropriate increase in prolactin release:
        • Usually supported by a prolactinoma:
          • A prolactin-producing benign tumor of pituitary gland
• Physiological nipple discharge:
  • Is a benign entity:
    • Usually bilateral
    • White, green, or yellow in color
    • It involves multiple ducts
    • Is associated with nipple squeezing
  • Some causes of physiological nipple discharge are:
    • Hypothyroidism
    • Medication side-effects
• Pathologic nipple discharge (PND):
  • Is defined as a clear, serous, or bloody nipple secretion (not green or milky):
    • It is spontaneous
    • Discharging from a single duct and unilateral
  • It is frequently caused by:
    • A benign lesion, such as:
      • Intraductal papilloma(s):
        • 35% to 56% of the cases
      • Ductal ectasia:
        • 6% to 59% of the cases
    • An underlying malignancy can be present in a percentage of cases:
      • Reported to be variable from 5% to 33%
  • Because to differentiate between a benign from a malignant etiology of a PND based on clinical and diagnostic assessment is not easy:
    • Surgical excision has been considered the main way for getting both definitive diagnosis and eliminating the symptom
• Clinical History and Physical Examination:
  • Clinical history plays an important role:
    • For evaluating the probability of malignancy
  • Predicting factors for malignancy in the presence of PND are:
    • BRCA 1 / 2 mutations
    • History of ipsilateral cancer
    • Previous breast biopsy with diagnosis of atypia
    • Age over 50 years:
      • In a study including 318 patients with nipple discharge (any fluid from the nipple, spontaneous discharge or observed during breast examination):
        • Seltzer has reported a higher incidence of breast cancer:
          • Equal to 9% in females over 50 (95 patients and 9 cancers):
            • While the incidence was of only 1.3% in younger patients (223 patients and 3 cancers)
  • Physical examination:
    • Has the aim of distinguishing between benign and pathological discharge and of verifying the presence of palpable mass or other associated findings
    • It usually includes:
      • A complete breast evaluation:
        • With inspection and palpation
        • Followed by a focused inspection of the nipple area:
          • Using a magnifying lamp
    • The physical examination is essential to investigate the:
      • Color of discharge
      • The number of ducts involved
      • The frequency of discharge (persistent or intermittent)
      • If it is unilateral or bilateral
    • A spontaneous single-pore bloody and clear discharge:
      • Is suspect for pathological discharge
• Mammography:
  • Represents the first conventional imaging technique to investigate nipple discharge:
    • At least after 39 years old
  • For patients with PND, aged between 30 and 40 years old with high-family risk:
    • Mammography could be appropriated in order to exclude the presence of microcalcifications
  • As well as for females younger than 30 of age:
    • When initial ultrasound shows suspicious findings
  • The protocol includes:
    • The standard cranio-caudal and mediolateral oblique views
  • Mammography findings that are suspect to be associated to an occult malignancy can range from:
    • Microcalcifications
    • Masses
    • Focal density asymmetry
    • Architectural distortion or ductal ectasia
    • Otherwise no abnormality can be identified
  • Mammography has low sensitivity and limited accuracy:
    • In the detection of retroareolar lesions that are often small, intraductal, and without calcifications
  • Ductal ectasia:
    • May occur as a general increase in density of the retroareolar region and in order to better visualize the area:
      • Spot compression views could be performed
  • In order to improve spatial resolution:
    • Magnification mammography can be performed:
      • To identify microcalcifications and to distinguish between benign or malignant duct disease
  • Microcalcifications with:
    • Branching or linear pattern, variable density, or distributed in a segmental way:
      • Are all highly suspicious of malignancy
    • Whereas round or rod-like calcifications:
      • Suggest for benign disease
  • Bahl et al studied 252 patients with at least one pathological feature of nipple discharge (unilateral, clear or bloody, or spontaneous discharge) who underwent surgical excision or a 2-year follow-up:
    • Of 20 cancers diagnosed:
      • Only three were revealed by mammography:
        • With a 15% (3/20) sensitivity
  • In other studies, the sensitivity of mammography:
    • Ranged from 7% to 26%. 
• Ultrasound:
  • Offers a better performance than mammography:
    • For detecting intraductal lesions
  • Ductal ectasia:
    • Defined by a duct caliber greater than 3 mm
      • Is one of the most common findings seen on ultrasound:
        • It appears as dilated retroareolar ducts containing anechoid fluid or hypoecoic debris
  • An intraductal papilloma appears as:
    • A hypoechoic nodule with a central vascular pedicle on color Doppler:
      • Doppler ultrasound is helpful in differentiating:
        • Intraductal viscous secretion versus intraductal nodule with vascular sign
  • Ultrasound malignant features are:
    • Irregular duct margins
    • Wall thickening
    • Hypoechoic intraductal mass with acoustic shadowing 
  • In a study by Park et al:
    • The detection rate of malignant lesions occult on mammography and ultrasound-detected:
      • Was reported to be 8 of 53 females with PND examined (15%)
  • Yoon et al:
    • Have also reported that adding ultrasound to mammography in the pre-operative setting of PND:
      • Led to the detection of malignancies in 26% of patients (ultrasound detected fivebreast cancers in addition to the 19 breast cancers found by mammography)
  • The role of ultrasound elastography is disputable in predicting malignancy in patients with PND:
    • Guo et al have evaluated the diagnostic accuracy of elastography in patients with PND:
      • Affirming that it is a useful tool for predicting malignancy:
        • With sensitivity for malignancy of 90% and that it could be used as a helpful test before more invasive examination (such as ductoscopy or duct excision):
          • However, it is only a preliminary study and further studies are needed to verify the diagnostic perfor- mance of elastography
• Nipple discharge cytology:
  • Is performed by squeezing the nipple with a gentle compression of the areola area and spreading the secretion onto a glass slide:
    • After smearing, the slides are immediately fixed by spray fixation or by immersion in 95% ethyl alcohol:
      • Then stained with the Papanicolaou stain
  • It is a simple and fast examination, easy to perform and painless:
    • But strongly limited by a low sensitivity for cancer:
      • With a false negative rate over 50%
    • Moreover, it can be technically impossible when discharge is not present on the moment of the examination
    • According to the American College of Radiology:
      • This examination has not proven to be effective in differentiating benign from malignant lesions:
        • Therefore, discharge cytology is not routinely recommended
  • Nipple discharge smears are classified as abnormal if they contained:
    • Papillary, atypical, suspicious, or malignant cells:
      • Malignant nipple discharge cytology is correlated with higher specificity values

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #Teacher #BreastCancer #NippleDischarge #PathologicNippleDischarge #PhysiologicNippleDischarge #CASO #Miami #CenterforAdvancedSurgicalOncology #IntraductalPapilloma #DuctalEctasia

👉Thyroid cancer is the only malignancy that has age as a prognostic factor in TNM staging.

👉Due to the favorable prognosis in younger patients the highest possible stage for patients less than 55 is Stage II

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #Teacher #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncologist #CASO #Miami #CenterforAdvancedSurgicalOncology

👉Up to 20% of patients with papillary thyroid cancer will experience recurrent disease after surgery throughout their lifetime.

👉Certain mutations (e.g. BRAFV600E) are independent risk factors for recurrence.

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #Teacher #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncologist #CASO #Miami #CenterforAdvancedSurgicalOncology