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• Accessory breast tissue:
  • Is an isolated parenchymal mass without a nipple-areolar complex
  • It occurs due to failed regression of primitive mammary tissue
  • It most often occurs in the axilla
• Unlike the tail of Spence;
  • Which is a normal extension of breast tissue to the underarm:
    • Accessory breast tissue of the axilla is not functionally connected to the breast
• Accessory breast tissue:
  • Is normal breast tissue
  • Is subject to the same benign and malignant conditions that can occur in the breast
• Ultrasound is the primary modality for evaluation:
  • Accessory breast tissue:
    • Can appear as either:
      • A purely glandular elements
      • Fibrous elements or 
      • A mixture of fibrous and glandular elements
• The mediolateral oblique (MLO) view on mammogram:
  • Is the best for imaging the lower aspect of the axilla and the axillary tail of the breast
• On breast magnetic resonance imaging (MRI):
  • Accessory breast tissue:
    • Can appear as a subcutaneous, poorly defined lesion that has contrast enhancement and signal intensity similar to the breast but is discontiguous with the rest of the breast parenchyma

• References:
  • Kulkarni D, Dixon JM. Congenital abnormalities of the breast. Women’s Health, 2012;8(1):75–88.
  • Lim HS, Kim SJ, Baek JM, Kim JW, Shin SS, Seon HJ, et al. Sonographic findings of accessory breast tissue in axilla and related diseases. J Ultrasound Med. 2017:36(7):1469-1478.
  • Patel BK, Jafarian N, Abbott AM, Khazai L, Lee MC. Imaging findings and management of primary breast cancer in accessory axillary breast tissue. Clin Breast Cancer. 2015 Aug;15(4):e223-9.

#Arrangoiz #BreastSurgeon #AccessoryBreastTissue #SurgicalOncology #CancerSurgeon #BreastCancer #Miami #Mexico

• The breast develops from the ectodermal “mammary ridge” or the “milk-line”:
  • Which extends from the future axilla to the groin
• The nipple and areola:
  • Develop from the ectoderm along the milk-line
• The majority are seen in the inframammary region
• Accessory nipples:
  • Are seen in 1% to 5% of the population although differences among ethnic groups can occur
  • The incidence is the same between male and females
  • They are prone to the same diseases as normal nipples but do not require an excision or treatment:
    • Unless the nipple cause irritation or cosmetic issues

• References:
  • Kulkarni D, Dixon JM. Congenital abnormalities of the breast. Women’s Health.2012;8(1):75–88.
  • Brown J, Schwartz RA. Supernumerary nipples: an overview. Cutis 2003:71(5):344–346.

#Arrangoiz #BreastSurgeon #BreastCancer #AccessoryNipples #CancerSurgeon #SurgicalOncologist #Miami #Mexico #Teacher

• There are multiple types of papillary breast lesions including:
  • Benign intraductal papillomas
  • Atypical papillomas
  • Papillomas with atypical ductal hyperplasia (ADH)
  • Papillary carcinomas
• A solitary intraductal papilloma:
  • Is a common breast lesion:
    • That can present with nipple discharge if arising in the large ducts, or
    • As a clinically occult mass on imaging if occurring in the periphery
    • Infrequently, an intraductal papilloma presents as a palpable mass
  • Typically, atypia or carcinoma in situ:
    • Is more frequently associated with intraductal papillomas in the periphery of the breast:
      • However, due to intralesional heterogeneity and fragmentation, sampling error is a concern with core needle biopsy
  • Recent studies suggest the risk of upgrade to carcinoma upon excision of an intraductal papilloma with atypia:
    • Is 21% to 37%:
      • Thus, removal of the entire lesion is sometimes required to rule out in situ or invasive cancer
  • A wide margin is not required at the time of excision biopsy of a papillary lesion
  • References:
    • Racz JM, Carter JM, Degnim AC. Challenging atypical breast lesions including flat epithelial atypia, radial scar, and intraductal papilloma. Ann Surg Oncol. 2017;24(10): 2842-2847.
    • Wei S. Papillary lesions of the breast: an update. Arch Pathol Lab Med. 2016;140(7):628-643
    • Swapp RE, Glazebrook KN, Jones KN, Brandts HM, Reynolds C, Visscher DW, et al. Management of benign intraductal solitary papilloma diagnosed on core needle biopsy. Ann Surg Oncol. 2013;20(6):1900-1905.
    • Cheng TY, Chen CM, Lee MY, Lin KJ, Hung CF, Yang PS, et al. Risk factors associated with conversion from nonmalignant to malignant diagnosis after surgical excision of breast papillary lesions. Ann Surg Oncol. 2009;16(12):3375-3379.
    • Ko D, Kang E, Park SY, Kim SM, Jang M, Yun B, et al. The management strategy of benign solitary intraductal papilloma on breast core biopsy. Clin Breast Cancer.2017;17(5):367-372.

#Arrangoiz #BreastSurgeon #BreastExpert #CancerSurgeon #SurgicalOncologist #BreastCancer #BreastNodule #IntraductalPapilloma #Miami #Mexico

• Rapidly and definitively establish the diagnosis:
  • Because ATC is a highly dedifferentiated cancer that retains few characteristics of noncancerous thyroid cells, attaining a definitive diagnosis can be challenging, yet critical
  • Time is also of the essence because of the very rapid growth rate of ATC and due to the importance of early intervention in minimizing catastrophic airway compromise
  • Differential considerations / mimics can include:
    • Primary thyroid lymphoma
    • SCC of the head and neck
    • Metastatic cancer:
      • Especially from lung
  • Early assessment of tumor mutations is key in expanding therapeutic options
  • Attain multidisciplinary team engagement and coordination:
    • Coordinate early multidisciplinary involvement of surgeons, radiation and medical oncologists, endocrinologists, and palliative care teams to arrive at options for best care
  • Determine extent of disease:
    • Staging with imaging is required to classify as stage IVA, IVB, IVC:
      • This is best done with FDG PET/CT and / or alternatively with dedicated body CT or MRI.
    • Extent of local invasion must also be evaluated in parallel to assist in surgical decision-making, and requires laryngoscopy
  • Undertake patient counseling to establish individualized patient goals of care:
    • Counseling must be provided by a team / individuals skilled in the surgical, medical, and palliative management of complex thyroid malignancies in which trade-offs counterbalancing risks and benefits with goals of care are completely discussed
    • This counseling should best involve not only the patient but also involve supportive individuals / family members
  • Evaluate Surgical Options:
    • The primary goals in stages IVA and IVB ATC patients within an aggressive approach to their care are:
      • Complete resection and prompt transition to adjuvant definitive-intention therapy:
        • As long-term survival may be attainable
      • Thus, surgical procedures should not generate a wound or result in complications:
        • That would prevent chemotherapy and radiation onset due to the risk of wound breakdown given the lack of data supporting an association between increased extent of surgery and improved survival outcomes
    • In IVC ATC, the limited benefit resulting from surgery must be carefully tempered in consideration of other available palliative approaches, including:
      • Radiation and systemic therapy
  • Surgical decision-making:
    • Rapidly assess resectability:
      • Determining tumor invasion of the larynx, trachea, esophagus, and status of the major vessels of the neck
    • Consider the need for tracheotomy, extent of thyroidectomy, neck dissection, and the need to avoid laryngectomy, esophageal resection, and major vessel reconstruction
    • Balancing morbidity from surgery with expected benefits within the context of patient-anticipated prognosis and individualized goals of care is paramount
    • Considerations:
      • Performance score / status.
      • Presence of distant metastasis
      • Extent of local invasion of trachea and esophagus
      • Need for urgent tracheostomy, understanding that placement of a tracheostomy results in immediate improvement in upper airway obstruction but requires significant education for care and understanding that tumor location and growth may make management of the tracheotomy complex.
      • Patient goals of care and willingness to accept anticipated morbidity of planned surgery
  • Nonsurgical management decision-making:
    • Other than surgery, options may include postoperative or primary chemoradiation versus palliative radiotherapy, systemic therapy, or best supportive care considered within the context of:
      • Patient goals of care and willingness to accept anticipated toxicities of presented options.
      • Patient performance status and comorbidities and their impacts on feasibility of planned care.
      • Trade-offs from one approach to care versus alternatives
      • Keep hospice / end-of-life care discussions in the foreground
      • Given the historically dire prognosis of ATC, especially if stage IVC, hospice should always be presented among care options:
        • Truth telling and realistic presentation of anticipated prognosis are critical in allowing sound patient decisions within their individual goals of care
        • For some patients, hospice may be preferable—even from the outset—in comparison with other alternative care options

#Arrangoiz #ThyroidSurgeon #CancerSurgeon #ThyroidExpert #HeadandNeckSurgeon #SurgicalOncologist #ThyroidCancer #ThyroidNodules #AnaplasticThyroidCancer #ATC #Miami #Mexico

In Graves’ disease, thyroid-stimulating antibodies are produced, causing overproduction of thyroid hormones, leading to hyperthyroidism. A blood test to check for these antibodies helps diagnose Graves’ disease.

• Efficacy for medullary thyroid cancer (MTC):
  • Was evaluated in 55 adult and pediatric (older than 12 years) patients with advanced or metastatic RET-mutant MTC:
    • Who had previously been treated with cabozantinib, vandetanib, or both:
      • The ORR was 69%
  • In addition, the drug was evaluated in 88 patients with advanced or metastatic RET-mutant MTC:
    • Who had not received prior treatment with cabozantinib or vandetanib:
      • The ORR for these patients was 73%
  • The trial also enrolled 19 patients with RET-positive thyroid cancer whose condition was refractory to radioactive iodine (RAI) treatment and who had received another prior systemic treatment:
    • The ORR was 79%
  • Eight patients had received only RAI:
    • The ORR for these patients was 100%
• In all the cases of thyroid cancer:
  • Among the patients who responded to treatment:
    • The response lasted longer than 6 months
• RET alterations account for the majority of medullary thyroid cancers and a meaningful percentage of other thyroid cancers
• A fact sheet from the company notes that RET mutations are found:
  • In about 60% of sporadic MTC cases
  • In over 90% of familial MTC cases
  • RET fusions are found in approximately 10% to 20% of papillary thyroid cancers
• The approval of selpercatinib means they now have a treatment option that selectively and potently inhibits RET
• In the LIBRETTO-001 trial:
  • The rate of discontinuations because of adverse reactions (ARs) was 5%
  • The most common ARs, including laboratory abnormalities (≥ 25%), were:
    • Increased aspartate aminotransferase level
    • Increased alanine aminotransferase level
    • Increased glucose level
    • Decreased leukocyte count
    • Decreased albumin level
    • Decreased calcium level
    • Dry mouth
    • Diarrhea
    • Increased creatinine level
    • Increased alkaline phosphatase level
    • Hypertension
    • Fatigue
    • Edema
    • Decreased platelet count
    • Increased total cholesterol level
    • Rash
    • Decreased sodium levels
    • Constipation
  • The most frequent serious AR (≥ 2%) was:
    • Pneumonia
• The FDA warned that selpercatinib can cause:
  • Hepatotoxicity, elevation in blood pressure, QT prolongation, bleeding, and allergic reactions
  • It may also be toxic to a fetus or newborn baby so should not be taken by pregnant or breastfeeding women
• The drug is currently being assessed in two phase 3 confirmatory trials:
  • LIBRETTO-531 involves treatment-naive patients with RET-positive MTC.

• ATA Guidelines in Anaplastic Thyroid Carcinoma:
  • Work-up:
    • Immediate diagnosis is essential
    • The biopsy should undergo molecular evaluation:
      • Including:
        • BRAF V600E mutation
    • Airway assessment is paramount
    • Staging including anatomic imaging (head to toe)
  • Role of surgery:
    • Only 10% of patients present with local disease that is resectable
    • Local disease:
      • Compete resection is standard
    • Neoadjuvant therapy (targeted therapy) followed by surgery when feasible:
      • Local regional disease that is borderline resectable or un-resectable with actionable mutations:
        • BRAF V600E mutation, ALK fusions, TRK fusion
        • CHEK point inhibitors
    • Palliative resection (rare indication)
    • Open biopsy for diagnosis:
      • When FNA or core needle biopsy is undetermined
  • Advance local disease:
    • Indication for tracheostomy:
      • First we must have an educated discussion with the patient:
        • Discuss prognosis
        • Concerns
        • Airway signs and symptoms
        • Wishes

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #ThyroidCancer #AnaplasticThyroidCancer #EndocrineSurgery #HeadandNeckSurgery #CancerSurgeon #SurgicalOncology

• My name is Rodrigo Arrangoiz I went to medical school at the Anahuac University in Mexico City, which is one of the most prestigious medical schools in Mexico:
  • I graduated Suma Cum Laude from this medical school and was the president of the medical student council

• My general surgery training was performed at Michigan State University:
  • Where I was named chief residentduring my fifth year of residency which was a great honor

• My complex surgical oncology fellowship which included  head and neck training was performed at the Fox Chase Cancer Center in Philadelphia, Pennsylvania

• At the same time, I undertook a Masters in Science (Clinical Research for Health Care Professionals) at Drexel University in Philadelphia, Pennsylvania

• I performed a two-year global online fellowship in Head and Neck Surgery and Oncology with the International Federations of Head and Neck Societies / Memorial Sloan Kettering Cancer Center

• I encountered patients with very complex problems, and the greatest lesson I learned was there are always treatment options, utilizing all different types of techniques including radiation, chemotherapy and surgery:
  • This comprehensive training has provided me with an extensive understanding of the multidisciplinary approach to treating patients with cancer
• I have developed a particularly strong interest in the surgical and multimodal treatment of patients with breast cancer, head and neck cancer (including thyroid and parathyroid cancer), and endocrine diseases (benign and malignant thyroid and parathyroid diseases), using traditional surgery, regional therapies, and minimally invasive techniques
• I am an expert in the treatment of thyroid cancer including; active surveillance for early, small papillary thyroid cancers, minimally invasive thyroid surgery, selective and comprehensive neck dissections
• For the management of parathyroid disease, I offer a minimally invasive radio-guided technique called MIRP (minimally invasive radio-guided parathyroidectomy) through a 2 cm incision which will allow the patient to have a great cosmetic result and quick return to normal life after the operation
• I am extremely aware of the impact that a breast cancer diagnosis has on a patient:
  • I do my best to promote a positive atmosphere in which to start my patients’ course of treatment and take the time to explain the pros and cons of each treatment option, so that they can make an informed decision
• My management philosophy also includes, not just an emphasis on successful treatment, but also preserving a good cosmetic outcome:
  • I feel fortunate to be a fellowship trained, very highly specialized clinician, because this combination of factors allows me, and our treatment team to focus on one thing all day, every day, and do it well:
    • Curing cancer:
      • I think there is nothing more rewarding that I could do as a clinician
• I hold my patients as my number one priority:
  • I will spend as much time as necessary educating, answering questions and providing guidance for each individual patient to help them throughout each stage of their management
  • I believe in honest discussions, where both the patients and family’s goals and expectations are openly communicated
  • We will work together as a team to put together an evidence based personalized treatment plan
  • My personal goal is to treat and care for every patient with the same compassion and honesty as if they were a friend or family member

• Current therapeutic options for low-risk papillary thyroid carcinoma:
  • A scoping evidence review https://onlinelibrary.wiley.com/doi/abs/10.1002/hed.26883…
• Most cases of thyroid carcinoma are classified as low risk:
  • These lesions can be treated with surgery, active surveillance, and percutaneous ablation:
    • However, there is lack of consensus and clear indications for a specific treatment selection
• The objective of this study is to review the literature regarding the indications for management selection for low-risk carcinomas:
  • Systematic review exploring inclusion and exclusion criteria used to select patients with low-risk carcinomas for treatment approaches
    • The search found 69 studies
• The inclusion criteria most reported were nodule diameter and histopathological confirmation of the tumor type
• The most common exclusions were lymph node metastasis and extra-thyroidal extension
• There was significant heterogeneity among inclusion and exclusion criteria according to the analyzed therapeutic approach
• Alternative therapeutic approaches in low-risk carcinomas can be cautiously considered
• Thyroidectomy remains the standard treatment against which all other approaches must be compared

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #EndocrineSurgery #HeadandNeckSurgery #SurgicalOncology #ThyroidCancer #PapillaryThyroidCancer #LowRiskThyroidCancer #Miami #Mexico

• Anaplastic thyroid cancer is the least common type of thyroid cancer:
  • Roughly 1% to 2% of all thyroid malignancies
    • But represents greater than 50% of all thyroid-cancer mortalities
  • Unlike papillary thyroid cancer, it’s very aggressive:
    • All new cases are considered Stage IV

• Anaplastic thyroid cancer overall survival:
  • T4a:
    • 15.8 months
  • T4b:
    • 6.1 months
  • T4c:
  • 2.8 months
• Reference:
  • Onoda N, Sugitani I, Ito KI, Suzuki A, Higashiyama T, Fukumori T, et al. Evaluation of the 8th edition TNM classification for anaplastic thyroid carcinoma. Cancers. 2020;12:111. https://thyroidresearchjournal.biomedcentral.com/…/s130…

#Arrangoiz #ThyroidSurgeon #ThyroidExpert #EndocrineSurgery #HeadandNeckSurgeon #CancerSurgeon #ThyroidCancer #AnaplasticThyroidCancer #Teacher #Miami #Mexico