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• The mammogram shows trabecular thickening and an increased thickness of the skin:
  • Trabecular thickening is an increased prominence of linear structures in the breast:
    • Primarily corresponding to Cooper’s ligaments
  • It is almost always seen in conjunction with skin thickening:
    • It indicates significant breast edema
  • It has a number of different causes, including:
    • Congestive heart failure
    • Renal failure
    • Venous or lymphatic obstruction
    • Diffusely infiltrating carcinoma
    • Radiation
  • When the cause is lymphatic obstruction:
    • The obstruction can be the result of surgery, radiation, or lymphatic invasion by cancer
• Unilateral breast edema with increased trabecular and skin thickening:
  • Sometimes occurs with congestive heart failure:
    • The pedal edema that develops during the daytime decreases at night:
      • And the fluid accumulates in the dependent breast in patients who sleep on their side
• References
  • Berg, WA, Birdwell RL, Kennedy A. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006.
  • Verbelen H, Gebruers N, Beyers T, De Monie AC, Tjalma W. Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: a systematic review. Breast Cancer Res Treat. 2014;147(3):463-471.
  • Wratten CR, O’Brien PC, Hamilton CS, Bill D, Kilmurray J, Denham JW. Breast edema in patients undergoing breast-conserving treatment for breast cancer: assessment via high frequency ultrasound. Breast J. 2007;13(3):266-273.
  • Menta A, Fouad TM, Lucci A, Le-Petross H, Stauder MC, Woodward WA, et al. Inflammatory breast cancer: what to know about this unique, aggressive breast cancer. Surg Clin North Am. 2018;98(4):787-800.

• Excisional biopsy:
  • Is recommended for most ADH lesions diagnosed on core needle breast biopsy (CNB):
    • The chance of upgrade at excision to ductal carcinoma in situ (DCIS) or invasive carcinoma:
      • Is generally in the 12% to 22% range in the literature
  • The need for routine excision of pure flat epithelial atypia (FEA) has been less clear:
    • Some authors have reported an upgrade rate of 9.6% following excision of lesions that show pure FEA without ADH:
      • When the vast majority of biopsies were done with a 14-gauge spring-loaded core biopsy device
  • It is not clear that biopsy with a vacuum-assisted device would yield the same results:
    • In fact, in one study reporting biopsy of low-risk calcifications with a vacuum-assisted device:
      • Pure FEA never resulted in an upgrade to malignancy
    • An article from the Mayo Clinic:
      • Showed that FEA does not seem to convey an independent risk of breast cancer beyond that of associated proliferative disease without atypia or associated ADH
• The risk of upgrade at surgical excision for ADH:
  • Has been reported to correlate with the number of ducts or terminal duct lobular units involved on vacuum-assisted core biopsy:
    • With 2 or fewer foci of involvement:
      • There was no upgrade on excision
    • With 4 or more foci of involvement:
      • There was a strong probability of upgrade to ductal carcinoma in situ or invasive carcinoma at excision
• Work continues to try to define a low-risk group who could potentially avoid excisional biopsy:
  • Particularly those with small areas of calcifications completely removed with core needle biopsy and only focal ADH on pathology
• Apocrine metaplasia, florid epithelial hyperplasia of the usual variety, and columnar cell change without atypia:
  • Do not confer a significant risk of upgrade and do not require excision
• References
  • Eby PR, Ochsner JE, DeMartini WB, Allison KH, Peacock S, Lehman CD. Is surgical excision necessary for focal atypical ductal hyperplasia found at stereotactic vacuum-assisted breast biopsy? Ann Surg Oncol. 2008;15(11):3232-3238.
  • Ely KA, Carter BA, Jensen RA, Simpson JF, Page DL. Core biopsy of the breast with atypical ductal hyperplasia: a probabilistic approach to reporting. Am J Surg Pathol. 2001;25(8):1017-1021.
  • Khoumais NA, Scaranelo AM, Moshonov H, Kulkarni SR, Miller N, McCready DR, et al. Incidence of breast cancer in patients with pure flat epithelial atypia diagnosed at core-needle biopsy of the breast. Ann Surg Oncol. 2013;20(1):133-138.
  • Said SM, Visscher DW, Nassar A, Frank RD, Vierkant RA, Frost MH, et al. Flat epithelial atypia and risk of breast cancer: a Mayo cohort study. Cancer. 2015;121(10):1548-1555.
  • McGhan LJ, Pockaj BA, Wasif N, Giurescu ME, McCullough AE, Gray RJ. Atypical ductal hyperplasia on core biopsy: an automatic trigger for excisional biopsy? Ann Surg Oncol. 2012;19(10):3264-3269.

• Patients who are candidates for surgery for primary hyperparathyroidism (PHPT) but have negative or discordant imaging findings by ultrasound or Sestamibi scan:
  • Should still undergo surgical evaluation according to American Association of Endocrine Surgeons guideilnes:
    • Please see guidelines:
      • https://jamanetwork.com/journals/jamasurgery/fullarticle/2542667

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

#Arrangoiz #ParathyroidSurgeon #ParathyroidExpert #Hyperparathyroidism #PrimaryHyperparathyroidism #CancerSurgeon #EndocrineSurgery #Teacher #Surgeon #HeadandNeckSurgeon #SurgicalOncologist #ParathyroidAdenoma #Hypercalcemia #ElevatedCalciumLevels #Miami #MountSinaiMedicalCenter #MSMC #Mexico #Hialeah

• Debate on adjunct screening in women with dense breasts has resulted from legislation mandating that women be informed if their mammograms show dense breast tissue, including:
  • Informing them that other screening modalities are available
• In addition to MRI and molecular imaging:
  • Both tomosynthesis and breast ultrasound are additional techniques for enhanced screening in patients with dense breasts
• Multiple studies show significant benefits from the addition of tomosynthesis to conventional digital mammography alone in screening programs:
  • Ciatto et al:
    • Found an increase in detection rate of invasive breast cancer from 5.3 / 1000 to 8.1 / 1000:
      • While also decreasing the recall rate by 17%
  • Skaane et al:
    • Found a 40% increase in the detection of invasive cancers:
      • With a 15% reduction in false negatives
  • Rose et al. and Haas et al:
    • Showed statistically significant relative reductions in recall rates of:
      • 37% and 30%, respectively
  • A recent retrospective review of 454,850 examinations in 13 screening centers in the United States:
    • Demonstrated a 41% increase in invasive cancer detection, a 15% reduction in call backs, and a 49% increase in the positive predictive value for recall
  • Implementation of tomosynthesis did not lead to a significant reduction in biopsy rates as compared to digital mammography screening:
    • As yet, there are no data that show a reduction in mortality with enhanced screening in dense breasts
• A prospective multicenter study compared tomosynthesis with bilateral physician hand-held ultrasound screening in 3,231 asymptomatic patients with mammography-negative dense breasts:
  • In all, 24 additional cancers were detected, 23 of which were invasive
  • Tomosynthesis detected 13 cancers, and ultrasound detected 23
  • These data suggest that even though tomosysthesis significantly increases the number of cancers found in dense breasts, in the hands of a skilled breast radiologist:
    • Ultrasound may be even better
• References
  • Ciatto S, Houssami N, Bernardi D, Caumo F, Pellegrino M, Brunelli S, et al. Integration of 3D digital mammography with tomosynthesis for population breast-cancer screening (STORM): a prospective comparison study. Lancet Oncol. 2013;14(7):583-589.
  • Skaane P, Bandos AI, Gullien R, Eben EB, Ekseth U, Haakenaasen U, et al. Comparison of digital mammography alone and digital mammography plus tomosynthesis in a population-based screening program. Radiology. 2013;267(1):47-56.
  • Haas BM, Kalra V, Geisel J, Raghu M, Durand M, Philpotts LE. Comparison of tomosynthesis plus digital mammography and digital mammography alone for breast cancer screening. Radiology. 2013;269(3):694-700.
  • Rose SL, Tidwell AL, Bujnoch LJ, Kushwaha AC, Nordmann AS, Sexton R Jr. Implementation of breast tomosynthesis in a routine screening practice: an observational study. AJR Am J Roentgenol. 2013;200(6):1401-1408.
  • Friedewald SM, Rafferty EA, Rose SL, Durand MA, Plecha DM, Greenberg JS, et al. Breast cancer screening using tomosynthesis in combination with digital mammography. JAMA. 2014;311(24):2499-2507.
  • Tagliafico AS, Calabrese M, Mariscotti G, Durando M, Tosto S, Monetti F, et al. Adjunct screening with tomosynthesis or ultrasound in women with mammography-negative dense breasts: interim report of a prospective comparative trial. J Clin Oncol. 2016;34(16):1882-1888.

• Ductal calcifications have a wide variety of presentations:
  • Depending upon the underlying process that created them
• When coarse rod-like ductal calcifications:
  • Are diffuse, bilateral, and not confined to a single lobe:
    • They can be confidently assumed to result from plasma cell mastitis:
      • They do not require further evaluation or biopsy (Image)
    • The process is called secretory disease:
      • Because there is a stagnant, viscous fluid that eventually petrifies and results in the smooth contoured calcifications
      • Some of them are branching and look like malignant casting type calcifications:
        • But the key distinguishing feature:
          • Is the diffuse, multilobe, bilateral nature of the process:
            • Calcifications become much more worrisome when they are confined to a single lobe

• The most frequent malignant, ductal “casting type” calcifications:
  • Are fragmented, linear, and branching:
    • They are the most reliable mammographic sign of malignancy (Image)
    • The presence of fragmented and / or dotted casting type calcifications on the mammogram:
      • Restricted to one lobe:
        • Is a pathognomonic sign of a diffuse, grade 3 breast cancer subtype that originates in the major ducts and usually has a solid or micropapillary pattern:
          • Traditionally, this subtype has been called “comedo carcinoma”:
            • The cancer cells either produce a viscous, proteinaceous fluid which gradually concentrates and eventually calcifies, or they undergo necrosis (apoptosis) followed by calcification
            • In both instances, the intraluminal pressure increases, distending the ducts considerably
  • Dotted casting type calcifications:
    • Have been referred to as “snakeskin-like calcifications”:
      • They accumulate in the fluid:
        • Produced by either micropapillary or solid cancer cell growth patterns (Image)

• The tips of the micropapillary growths may become detached and eventually calcify, contributing to the intraluminal calcifications (Image).

• Occasionally, malignant ductal calcifications present in a manner that can be easily mistaken for a benign process:
  • It occurs when fluid production:
    • Rather than necrosis, dominates the picture
  • The intraductal carcinoma can be grades 1, 2, or 3 and a micropapillary and / or cribriform architecture is present
  • Tabár has done extensive work comparing the mammographic images with 3D subgross sections and whole mount histology slides in order to determine that the calcification occurs in large lakes of fluid that calcify, forming round or oval, discoid calcifications:
    • He credits Stavros with suggesting the name “skipping stone” calcifications because they are reminiscent of stones that children skip across a pond (Images 5a, 5b, 6, and 7)

• A variation of this type of calcification occurs in grades 1 and 2 fluid-producing intraductal carcinomas when large psammoma body-like calcifications develop in the ducts in a pattern suggestive of a “string of pearls”

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #BreastCancer #BreastImaging #MountSinaiMedicalCenter #MSMC #Miami #Mexico

Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirugia endocrina es experto en el manejo del hiperparatiroidismo primario.

Introdujo a su país (Mexico) la técnica de exploración bilateral de cuello con valoración de la funcionalidad de las glándulas paratiroides con paratiroidectomia radioguiada:

Rodrigo Arrangoiz is a board-certified surgical oncologist who subspecializes in breast cancer and head and neck cancer. Dr. Arrangoiz earned his medical degree at the Anahuac University Medical School in Mexico City, Mexico and graduated Suma Cum Laude. He completed his internship and residency in general surgery at Michigan State University, where he was named chief resident during his fifth year of residency. Dr. Arrangoiz also completed a complex surgical oncology, head and neck fellowship at the Fox Chase Cancer Center in Philadelphia and at the same time he undertook a master’s in science (Clinical Research for Health Care Professionals) at Drexel University in Philadelphia. Dr. Arrangoiz also participated in a two-year global online fellowship in head and neck surgery and oncology through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center.

Dr. Arrangoiz has participated in multiple courses and academic congresses as a lecturer and guest professor and has also participated in several publications on topics related to his specialty that include oral cavity cancer, hyperparathyroidism, thyroid cancer, breast cancer, endocrine tumors, squamous cell carcinoma of the head and neck, and more. He is board certified by the American Board of Surgery, the Mexican Board of General Surgery and the Mexican Board of Oncology.

He is a member of various medical associations such as the American College of Surgeons, American Thyroid Association, American Head and Neck Society, American Medical Association, American Society of Clinical Oncology, Association of Academic Surgeons, Society of Surgical Oncology, The Society of Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons, and the American Society of Breast Surgeons, among others.

Specialty:

Head and Neck Surgery
Thyroid and Parathyroid Surgery
Breast Surgery
Complex Surgical Oncology

Areas of Clinical Interest:

Malignant thyroid disease (papillary, follicular, medullary, anaplastic thyroid cancer, thyroid lymphoma, and metastatic disease to the thyroid gland) benign thyroid diseases (goiter, multinodular goiter, substernal goiter, hyperthyroidism), hyperparathyroidism / hypercalcemia, benign and malignant breast diseases, head and neck surgery and head and neck cancer.

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

#Hyperparathyroidism

#Hiperparatiroidism

#MountSinaiMedicalCenter

#MSMC

#Miami

#Mexico

Assistant Professor at the Columbia University Division of Surgical Oncology at Mount Sinai Medical Center

• Head and Neck Surgery
• Thyroid and Parathyroid Surgery
• Breast Surgery
• Complex Surgical Oncology
• 305.674.2397
• Fax: 305.674.2708

• 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 resident during 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 cancerincluding; 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

Assistant Professor at the Columbia University Division of Surgical Oncology at Mount Sinai Medical Center

• Rodrigo Arrangoiz MS, MD, FACS:
  • Is a a cancer surgeon that specializes in Breast Surgery, Head and Neck Surgery, Endocrine Surgery, and Complex Surgical Oncology.
• He graduated Suma Cum Laude:
  • From one of the top medical schools in Mexico called Anahuac University as a medical doctor (MD)
• He is an Assistant Professor at the Columbia University Division of Surgical Oncology at Mount Sinai Medical Center
• Dr. Arrangoiz is an expert in managing thyroid cancer, benign thyroid diseases, primary hyperparathyroidism, breast diseases, breast cancer, skin cancer and Head and Neck Tumors.
• He was trained in the best academic institutions in the United States and maintains certifications by the Board of General Surgery and Surgical Oncology in Mexico and the United States.
• His training included:
  • General and Gastrointestinal Surgery – Michigan State University (2004 – 2010)
  • Oncological Surgery / Head and Neck Tumors / Endocrine Surgery –Fox Chase Cancer Center in Philadelphia (2010 to 2012)
  • Master of Science (Clinical Research for Health Professionals) –Drexel University (Philadelphia) (2010 – 2012)
  • Head and Neck Tumor Surgery / Endocrine Surgery (2014 to 2016) – IFHNOS / Memorial Sloan Kettering Cancer Center
• He has participated in multiple courses and congresses as a Lecturer and Guest Professor, and has published multiple articles on topics related to his specialty.
• He is a member of various medical associations including the American College of Surgeons, American Thyroid Association, American Society of Endocrine Surgeons, American Medical Association, American Society of Clinical Oncology, Association of Academic Surgeons, Society of Surgical Oncology, The Society of Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons,and the American Society of Breast Surgeons , among others.
• Thanks to this, Dr. Rodrigo Arrangoiz is one of the most well respected Head and Neck surgeons in Mexico, in addition to being awarded as one of the 50 best doctors in Mexico in the Top Doctors Awards 2018 and Top Doctors Awards 2019.
• Specialty:
  • Head and Neck Surgery
  • Thyroid and Parathyroid Surgery
  • Breast Surgery
  • Complex Surgical Oncology
• Areas of Clinical Interest:
  • Malignant thyroid disease (papillary, follicular, medullary, anaplastic thyroid cancer, thyroid lymphoma, and metastatic disease to the thyroid gland) benign thyroid diseases (goiter, multinodular goiter, substernal goiter, hyperthyroidism), hyperparathyroidism / hypercalcemia, benign and malignant breast diseases, head and neck surgery and head and neck cancer.

Rodrigo Arrangoiz MS, MD, FACS cirujano de tumores de cabeza y cuello / cirujano de paratiroides / cirugía endocrina / cirugía oncológica miembro de Mount Sinai Medical Center …

¿Estás Cansado, Podrías Tener Hiperparatiroidismo Primario

👉https://m.youtube.com/watch?v=AgvQmtz1gnA&time_continue=127

Rodrigo Arrangoiz MS, MD, FACS, FSSO cirujano de tumores de cabeza y cuello / cirugia endocrina es experto en el manejo del hiperparatiroidismo primario.

Introdujo a su país la técnica de exploración bilateral de cuello con valoración de la funcionalidad de las glándulas paratiroides con paratiroidectomia radioguiada

r. Rodrigo Arrangoiz is a board-certified surgical oncologist who subspecializes in breast cancer and head and neck cancer. Dr. Arrangoiz earned his medical degree at the Anahuac University Medical School in Mexico City, Mexico and graduated Suma Cum Laude. He completed his internship and residency in general surgery at Michigan State University, where he was named chief resident during his fifth year of residency. Dr. Arrangoiz also completed a complex surgical oncology, head and neck fellowship at the Fox Chase Cancer Center in Philadelphia and at the same time he undertook a master’s in science (Clinical Research for Health Care Professionals) at Drexel University in Philadelphia. Dr. Arrangoiz also participated in a two-year global online fellowship in head and neck surgery and oncology through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center.

Dr. Arrangoiz has participated in multiple courses and academic congresses as a lecturer and guest professor and has also participated in several publications on topics related to his specialty that include oral cavity cancer, hyperparathyroidism, thyroid cancer, breast cancer, endocrine tumors, squamous cell carcinoma of the head and neck, and more. He is board certified by the American Board of Surgery, the Mexican Board of General Surgery and the Mexican Board of Oncology.

He is a member of various medical associations such as the American College of Surgeons, American Thyroid Association, American Head and Neck Society, American Medical Association, American Society of Clinical Oncology, Association of Academic Surgeons, Society of Surgical Oncology, The Society of Surgery of the Alimentary Tract, Society of American Gastrointestinal Endoscopic Surgeons, and the American Society of Breast Surgeons, among others.

Specialty:

Head and Neck Surgery
Thyroid and Parathyroid Surgery
Breast Surgery
Complex Surgical Oncology

Areas of Clinical Interest:

Malignant thyroid disease (papillary, follicular, medullary, anaplastic thyroid cancer, thyroid lymphoma, and metastatic disease to the thyroid gland) benign thyroid diseases (goiter, multinodular goiter, substernal goiter, hyperthyroidism), hyperparathyroidism / hypercalcemia, benign and malignant breast diseases, head and neck surgery and head and neck cancer.

Su entrenamiento fue el siguiente:

• Cirugia general y gastrointestinal:
• Michigan State University:
• 2004 al 2010• Cirugia oncológica / tumores de cabeza y cuello / cirugia endocrina:
• Fox Chase Cancer Center (Filadelfia):
• 2010 al 2012• Maestria en ciencias (Clinical research for healthprofessionals):
• Drexel University (Filadelfia):
• 2010 al 2012• Cirugia de tumores de cabeza y cuello / cirugiaendocrina
• IFHNOS / Memorial Sloan Kettering Cancer Center:
• 2014 al 2016

#Arrangoiz

#CirugiadeTumoresdeCabezayCuello

#CirugiaEndocrina

#CirugiaOncologica

#HeadandNeckSurgery

#EndocrineSurgery

#SurgicalOncology

#Hyperparathyroidism

#Hiperparatiroidismo