Ectopic thyroid tissue

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Ectopic Thyroid Tissue

Embryological Basis

The thyroid gland originates from the floor of the primitive pharynx during the third week of gestation, at the site of the foramen cecum at the base of the tongue. It then migrates caudally along the thyroglossal duct to its final pretracheal position in the lower neck. Ectopic thyroid results from failure or arrest of this descent at any point along this path.

The transcription factors TTF-1, TTF-2, NKX2-1, FOXE1, and PAX8 orchestrate thyroid gland development; mutations in these genes can cause thyroid dysgenesis, including ectopic positioning.

Harrison's Principles of Internal Medicine 22E, p. 3064
The Developing Human (Clinically Oriented Embryology), p. 498

Locations

Ectopic thyroid can occur anywhere along the thyroglossal duct tract - from the foramen cecum down to the anterior mediastinum. A second pathway (the thyrothymic tract, from the 3rd pharyngeal pouch) extends inferiorly to the mediastinum.

Sites of ectopic thyroid tissue along the thyroglossal duct tract

Usual sites of ectopic thyroid tissue along the path of the thyroglossal duct. - The Developing Human, p. 498

Midline ectopic thyroid sites and thyrothymic thyroid rests

(A) Common sites for midline ectopic thyroid masses (lingual, sublingual, infrahyoid, prethyroid, isthmus, mediastinal). (B) Major medial and lateral embryological elements including thyrothymic thyroid rests. - Sabiston Textbook of Surgery, p. 1486

Named Locations

Site	Notes
Lingual thyroid	Most common ectopic location; at the base of the tongue at the foramen cecum; found in up to 10% of autopsies, clinically relevant in 1/4000
Sublingual thyroid	Appears high in the neck at or just inferior to the hyoid bone due to incomplete descent
Infrahyoid / Prethyroid	Along the midline of the neck
Thyroglossal duct remnant	Thyroid tissue within a persistent thyroglossal duct cyst
Intrathoracic / Mediastinal	Arise from thyroid rests along the thyrothymic tract; can enlarge to form primary intrathoracic goiters
Struma ovarii	Ectopic thyroid tissue comprising >50% of an ovarian teratoma; rare; can be benign or malignant

Key Clinical Points

1. Lingual Thyroid

Presents as a midline mass at the base of the tongue.
Often the only thyroid tissue present - in ~70% of ectopic sublingual thyroid cases, no other thyroid tissue exists in the normal cervical position.
Can enlarge due to inadequate thyroid hormone production (compensatory TSH stimulation), causing dysphagia, dysphonia, or airway obstruction.
Surgical excision may be necessary for compressive symptoms.

2. Sublingual Thyroid

Sublingual thyroid mass and scintigraphy

A sublingual thyroid mass in a child. Tc-99m scintigraphy confirms ectopic sublingual thyroid (asterisk) with no functioning thyroid in the normal anterior neck position. - The Developing Human, p. 499

3. Thyroid Rests (Thyrothymic Tract)

Foci of thyroid tissue along the path of thymic descent; found in up to 50% of people and generally not pathological.
May be mistaken for pathologic lymph nodes or parathyroid glands.
Can be connected to the main gland by a thin stalk or exist as completely separate structures.
Enlargement of intrathoracic rests gives rise to primary intrathoracic goiters.

4. Struma Ovarii

Part of an ovarian teratoma; can produce thyroid hormone and cause thyrotoxicosis with low radioiodine uptake in the neck.
Listed alongside thyrotoxicosis factitia and iodine excess as a cause of thyrotoxicosis with low/absent thyroidal radionuclide uptake on scan.

Diagnosis

Ultrasound is the first-line investigation, especially to confirm the absence of normal cervical thyroid tissue.
Tc-99m pertechnetate scintigraphy confirms functional ectopic tissue and is essential before any surgical excision to avoid removing the patient's only functioning thyroid tissue.
CT/MRI for deeper or mediastinal locations.

Critical point: It is essential to differentiate ectopic thyroid from a thyroglossal duct cyst before surgery. Inadvertent removal of the only functioning thyroid tissue will render the patient permanently hypothyroid and dependent on lifelong thyroid hormone replacement.

Complications and Associations

Congenital hypothyroidism - ectopic thyroid is a leading cause; ectopic glands are often insufficient producers of thyroid hormone, triggering compensatory goitrous enlargement under elevated TSH.
Malignant transformation - thyroid cancers (papillary carcinoma most common) can arise in ectopic thyroid tissue including lingual thyroid and struma ovarii.
Thyrotoxicosis - rarely, from hyperfunctioning ectopic tissue (struma ovarii, functional teratomas).

Sources:

The Developing Human: Clinically Oriented Embryology, pp. 498-499
Sabiston Textbook of Surgery, pp. 1485-1486
Harrison's Principles of Internal Medicine, 22E, p. 3064
Cummings Otolaryngology, Head and Neck Surgery
Mulholland and Greenfield's Surgery, 7th ed.

Retrosternal goiter

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"retrosternal goiter" AND surgery

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Retrosternal Goiter

Also called substernal, intrathoracic, or diving goiter - these are terms used interchangeably, though "retrosternal" strictly refers to goiters behind the sternum while "intrathoracic" denotes at least 50% of thyroid tissue located below the thoracic inlet. It affects less than 1% of all goiter patients.

Classification

1. Secondary (Cervical Extension) - ~99%

The vast majority arise from downward extension of a cervical multinodular goiter along the fascial planes of the neck, drawn by gravity and negative intrathoracic pressure. These maintain their blood supply from the superior and inferior thyroid arteries (cervical vessels).

2. Primary (True Intrathoracic) - ~1%

Arise from ectopic accessory thyroid tissue within the chest, with no connection to cervical thyroid. They are supplied by intrathoracic blood vessels (internal mammary, innominate, or aortic branches). These are more likely to require a thoracic approach.

Schwartz's Principles of Surgery, 11th ed. | Sabiston Textbook of Surgery

Clinical Presentation

About 40% can be asymptomatic, presenting as an incidental finding on chest X-ray or CT.

When symptomatic:

Symptom	Mechanism
Dyspnea / airway obstruction	Tracheal compression (most common; acute distress in up to 20%)
Dysphagia	Esophageal compression
Stridor	Fixed tracheal narrowing (worse on exertion)
Hoarseness	Recurrent laryngeal nerve compression
SVC syndrome	Venous distension of neck/chest wall, facial oedema, plethora, cyanosis, papilloedema
Horner's syndrome	Sympathetic chain compression
Chylothorax	Thoracic duct compression
TIAs	Thyrocervical steal

Pemberton's Sign

Raising both arms above the head causes facial congestion, cyanosis, and respiratory distress due to functional obstruction of the thoracic inlet by the goiter. This is a classic clinical sign of increased thoracic inlet pressure.

Scott-Brown's Otorhinolaryngology, Head & Neck Surgery, p. 868

Investigations

Chest X-Ray

The classic finding is a superior mediastinal mass with tracheal deviation or compression, often discovered incidentally.

CXR: incidental finding of a mediastinal mass due to primary intrathoracic goiter. - Scott-Brown's, p. 868

CT Scan (Investigation of Choice)

The most important preoperative investigation. Key features to document:

Full inferior extent of the intrathoracic component (scan from skull base to carina)
Mediastinal compartment - anterior vs. posterior (posterior location increases the chance of lateral thoracotomy)
Tracheal deviation and compression - degree and level
Relationship to great vessels (innominate, SVC, aortic arch)
Evidence of malignancy (extracapsular extension)

CT findings that predict sternotomy: extension below the aortic arch, evidence of extra-thyroid extension suggesting malignancy, posterior mediastinal location, or primary intrathoracic goiter.

For substernal goiter evaluation, non-contrast CT is sufficient. IV contrast is added only if malignancy is suspected.

CT showing left substernal goiter with tracheal compression and deviation

CT scan: (A) Left-sided substernal goiter extending into the posterior mediastinum with tracheal compression and deviation. (B) Contrast CT showing locally advanced follicular thyroid cancer with tracheal wall and esophageal invasion. - Sabiston Textbook of Surgery, p. 1494

Thyroid Function Tests

Majority are euthyroid (80%)
Up to 30% may have subclinical thyrotoxicosis (suppressed TSH with normal T3/T4)
Overt hyperthyroidism is less common

Ultrasound

Cannot evaluate the intrathoracic component. Useful only for cervical thyroid morphology.

Scintigraphy

Plays no role in the preoperative evaluation of biochemically euthyroid patients
Intrathoracic goiters often demonstrate limited iodine avidity despite large size
May be useful when ectopic functioning tissue is suspected as a cause of thyrotoxicosis

Pulmonary Function Tests

Objective assessment of respiratory compromise - flow-volume loops may demonstrate a fixed extrathoracic or variable intrathoracic obstruction pattern.

Risk of Malignancy

Reported in up to 11% of goiters with intrathoracic extension - FNA where accessible.

Management

Indications for Surgery

Significant airway compression
Symptomatic patients (dysphagia, dyspnoea)
Young patients in whom symptoms are likely to develop
Suspected or confirmed malignancy

In elderly patients with incidentally discovered retrosternal goiters and no symptoms, most surgeons favour observation rather than prophylactic surgery, balancing operative risk against benefit.

Surgical Approach

Transcervical (Collar) Incision - >95% of cases

The standard and most common approach. Key steps:

Ligate and divide superior pole vessels and middle thyroid veins first
Divide the isthmus early to allow independent mobilization of each lobe
Blunt finger dissection along the thyroid capsule to free fascial attachments
Large 1-0 or 2-0 sutures placed deep into the goiter to facilitate traction and delivery through the neck
Ligamentous tissue between the sternal heads of the clavicles may be gently divided to increase the opening

Median Sternotomy - Indications (~5%)

Required in:

Invasive thyroid malignancy
Previous thyroid surgery (risk of parasitic mediastinal vessels from prior operations)
Primary intrathoracic goiter with no cervical thyroid tissue
Posterior mediastinal extension (may require lateral thoracotomy instead)
Goiter too large to deliver through the cervical incision

Incisions for partial sternotomy - collar incision extended with midline sternal split to the 3rd intercostal space

Incisions for partial sternotomy: collar incision combined with midline sternal division to the 3rd intercostal space, then laterally at the 3rd-4th intercostal space. - Schwartz's Principles of Surgery

The chest should be prepared and draped in all cases of substernal goiter surgery in the event emergency sternotomy is needed to control mediastinal bleeding or remove an unexpectedly invasive cancer.

Complications of Surgery

Recurrent laryngeal nerve injury - risk is increased due to altered anatomy and limited visibility
Hypoparathyroidism - parathyroids may be adherent or displaced
Tracheomalacia - softening of tracheal rings from chronic compression; may cause airway collapse post-extubation ("tracheal kiss") - requires awake extubation planning
Mediastinal haemorrhage
Chylothorax

Recent Evidence (2025)

A 2025 systematic review (Miani et al., Acta Otorhinolaryngol Ital, PMID: 40567093) covering 93 articles confirms that transcervical excision remains the most common approach for intrathoracic goiters, while transthoracic approaches must always be planned for. Surgery should be performed at specialist centres with experienced multidisciplinary teams to minimize complications.

A concurrent 2025 systematic review and meta-analysis (Alqutub et al., J Surg Res, PMID: 40850248) specifically examined predictors of sternotomy in substernal goiter - the key factors identified include posterior mediastinal extension, primary intrathoracic location, prior neck surgery, and goiter extension below the aortic arch.

Sources:

Sabiston Textbook of Surgery, pp. 1485-1494
Schwartz's Principles of Surgery, 11th ed., pp. 1083-1092
Bailey and Love's Short Practice of Surgery, 28th ed., pp. 882, 5211-5224
Scott-Brown's Otorhinolaryngology, Head & Neck Surgery, pp. 867-869
Cummings Otolaryngology, Head and Neck Surgery, p. 220

Thyroid swelling or case btao pura cover the viva qsn

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Thyroid Swelling - Complete Surgical Viva Guide

1. HOW DO YOU RECOGNIZE A THYROID SWELLING?

"A thyroid swelling is recognized by its position, its shape, and by the fact that it moves upwards during deglutition."

S Das, A Manual on Clinical Surgery

Why does it move on swallowing? Because the thyroid gland is enclosed within the pretracheal fascia, which is attached to the larynx and trachea - these structures move upward during swallowing, carrying the thyroid with them.

Exception (viva trap): Very large, fixed malignant thyroid masses may NOT move on swallowing because they have infiltrated surrounding structures.

Other swellings that move on swallowing: Thyroglossal cyst, subhyoid bursitis. Malignant/tuberculous lymph nodes fixed to trachea may also move.

Thyroglossal cyst vs thyroid swelling: A thyroglossal cyst moves up additionally when the tongue is protruded (because of its attachment to the foramen cecum via the thyroglossal tract). A thyroid swelling does NOT move on tongue protrusion.

2. CLASSIFICATION OF THYROID SWELLINGS (Das Classification)

(a) Non-toxic (Simple) Goitre

Diffuse parenchymatous (hyperplastic)
Colloid goitre
Multinodular goitre
Solitary nodular goitre

(b) Toxic Goitre

Diffuse toxic - Graves' Disease (Primary thyrotoxicosis)
Toxic multinodular goitre (Secondary thyrotoxicosis)
Toxic adenoma (Plummer's disease - Tertiary/solitary toxic nodule)

(c) Neoplastic

Benign - Follicular adenoma
Malignant - Papillary, Follicular, Medullary, Anaplastic, Lymphoma

(d) Thyroiditis

Acute bacterial (suppurative)
Granulomatous (de Quervain's / subacute)
Autoimmune - Hashimoto's (lymphocytic)
Riedel's (fibrous / woody thyroiditis)
Chronic bacterial (TB, syphilis)

(e) Other rare - Amyloid goitre, etc.

3. HISTORY TAKING

Presenting Complaint

Duration of swelling (long history = benign; rapidly growing = malignant or anaplastic)
Mode of onset: sudden increase in size suggests haemorrhage into a nodule
Pain: usually absent; pain suggests thyroiditis, acute suppurative, or haemorrhage
Rate of growth

Symptoms of Pressure (Compressive symptoms)

Dysphagia - esophageal compression
Dyspnoea / stridor - tracheal compression
Hoarseness of voice - RLN involvement (DANGER sign - suggests malignancy)
Venous engorgement - SVC / neck vein compression

Symptoms of Thyroid Dysfunction

Hyperthyroidism: Palpitations, weight loss despite good appetite, heat intolerance, excessive sweating, tremor, diarrhea, irritability, oligomenorrhea

Hypothyroidism: Weight gain, cold intolerance, constipation, lethargy, dry skin, hair loss, menorrhagia, bradycardia

Relevant History

Endemic area? (Iodine deficiency)
Goitrogenic diet - cabbage, cauliflower, brassica family, soya
Antithyroid drugs / lithium / amiodarone
Radiation exposure (neck irradiation in childhood - risk of papillary Ca)
Family history - MEN 2A/2B (medullary thyroid Ca), familial papillary Ca
Age and sex - female:male = 6:1 for goitre; males have higher risk of malignancy in a thyroid nodule
Pregnancy / puberty - physiological goitre

4. EXAMINATION - SYSTEMATIC APPROACH

Expose Patient Properly

Neck exposed down to the nipple level; collar removed; patient seated with neck slightly extended.

General Examination

Look for signs of thyroid dysfunction:

Feature	Hyperthyroid	Hypothyroid
Built	Thin	Obese/puffy
Skin	Warm, moist, velvety	Dry, coarse, cold
Hair	Fine, thinning	Coarse, thin, brittle
Pulse	Tachycardia, AF	Bradycardia
Eyes	Exophthalmos, lid lag, lid retraction	Periorbital puffiness
Hands	Tremor, palmar erythema	Dry, cold
Reflexes	Brisk	Slow-relaxing

Specific eye signs (Graves' Disease):

Exophthalmos (proptosis) - due to retroorbital infiltration
Lid lag (von Graefe's sign) - upper lid lags behind descending eyeball
Lid retraction (Dalrymple's sign) - sclera visible above iris
Infrequent blinking (Stellwag's sign)
Convergence weakness (Moebius sign)
Joffroy's sign - absent forehead wrinkling when looking up

Local Examination of the Thyroid

INSPECTION (stand in front, then side)

Note:

Site - midline vs lateral
Size - rough estimate
Shape - diffuse vs nodular
Number of swellings - solitary vs multiple nodules
Surface - smooth vs nodular
Skin - normal / red (inflammation) / dilated veins / fixation
Symmetry - which lobe is more enlarged
Visible pulsation - thyrotoxic goitre may pulsate
Move on swallowing - ask patient to swallow water; watch the swelling

PALPATION (stand behind the patient)

Ask patient to slightly flex the neck (relaxes sternomastoid).

Note:

Temperature - warm in thyroiditis, normal in simple goitre
Tenderness - present in thyroiditis, haemorrhage into nodule
Size and extent - measure lobes; feel for substernal extension (lower border not felt = retrosternal)
Surface - smooth vs nodular
Consistency:
- Soft/elastic = colloid goitre, simple goitre
- Firm = adenoma, multinodular
- Hard/stony = malignancy (papillary, anaplastic), calcification, Riedel's
- Rubbery/firm = Hashimoto's (like cartilage), lymphoma
- Cystic = colloid cyst, haemorrhage, thyroglossal cyst
Mobility - freely mobile vs fixed (fixation = malignancy)
Confirmation of movement on swallowing
Carotid pulsation - "Berry's sign": in malignant goitre, the carotid pulsation is absent on the affected side because the malignant thyroid mass envelops the carotid artery
Cervical lymph nodes - palpate all groups; enlarged nodes = malignancy / Hashimoto's

PERCUSSION

Percuss over the manubrium sterni - dull note indicates retrosternal extension

AUSCULTATION

Bruit over the thyroid = hypervascular gland (Graves' disease, thyrotoxicosis)
Must differentiate from a carotid bruit (heard in the neck, not directly over the gland)

PEMBERTON'S SIGN

Ask patient to raise both arms above the head. Positive = facial congestion, cyanosis, elevation of JVP, respiratory distress. Indicates functional obstruction of the thoracic inlet - suggests retrosternal goitre.

KOCHER'S TEST (Tracheal Compression Test)

Gently compress the thyroid laterally with fingers. Positive = stridor produced, indicating tracheal compression (narrowed trachea).

5. FEATURES SUGGESTING MALIGNANCY (Viva Favourite!)

Feature	Significance
Stony hard consistency	Papillary Ca, anaplastic, calcification
Rapid growth	Anaplastic carcinoma
Hoarseness	RLN involvement
Fixation to surrounding structures	Invasion by malignancy
Dysphagia (late)	Esophageal invasion
Cervical lymphadenopathy	Nodal metastases (especially papillary Ca - bilateral nodes)
Berry's sign	Carotid enveloped by malignant mass
Male patient with solitary nodule	Higher malignancy risk
Children with nodule	Higher malignancy risk (~50%)
History of neck irradiation	Papillary Ca
Solitary nodule (vs multinodular)	Relatively higher risk of malignancy

6. INVESTIGATIONS

Biochemical

Serum T3, T4, TSH - essential to determine functional status
- TSH low + T3/T4 high = hyperthyroid
- TSH high + T3/T4 low = hypothyroid
- TSH suppressed with normal T3/T4 = subclinical hyperthyroidism
Thyroid antibodies:
- Anti-TPO antibody - Hashimoto's (>95%)
- Anti-TSH receptor (TRAb / TSIG) - Graves' disease
- Anti-thyroglobulin antibody
Serum calcitonin - if medullary thyroid carcinoma suspected (MEN 2)
Serum thyroglobulin - tumour marker for differentiated thyroid cancer (post-thyroidectomy surveillance)
Serum calcium - pre-operatively (parathyroid function)

Imaging

Investigation	When/Why
Ultrasound neck	First-line for all thyroid swellings; size, cystic vs solid, nodule characteristics (TIRADS)
FNAC (Fine Needle Aspiration Cytology)	Gold standard investigation for a thyroid nodule; Bethesda system reporting
Radioisotope scan (Tc-99m or I-123)	Hot/warm/cold nodule characterization; ectopic thyroid; post-thyroidectomy remnant
CT neck + chest	Retrosternal extension; tracheal compression; malignancy staging
MRI	Same as CT without radiation; good for soft tissue detail
X-ray chest	Tracheal deviation, mediastinal widening, retrosternal goitre
X-ray neck	Tracheal deviation; soft tissue calcification (papillary Ca - psammoma bodies)
Laryngoscopy	Pre-op assessment of vocal cord mobility; if hoarseness present

FNAC - Bethesda System

Category	Risk of Malignancy	Management
I - Non-diagnostic	-	Repeat FNAC
II - Benign	<3%	Observe
III - AUS/FLUS	~10-30%	Repeat / molecular testing
IV - Follicular neoplasm	25-40%	Hemithyroidectomy
V - Suspicious for malignancy	60-75%	Near-total/total thyroidectomy
VI - Malignant	>97%	Surgery

Viva trap: FNAC cannot distinguish follicular adenoma from follicular carcinoma - this requires histology (capsular and vascular invasion). Hence Category IV requires diagnostic hemithyroidectomy.

Radioisotope Scan

Hot nodule = increased uptake = functioning = almost never malignant (Toxic adenoma)
Cold nodule = decreased uptake = non-functioning = 10-15% chance of malignancy
Warm nodule = same uptake as rest of gland

7. DIFFERENTIAL DIAGNOSIS OF A MIDLINE NECK SWELLING

Condition	Key Features
Thyroid swelling	Moves on swallowing; does NOT move on tongue protrusion
Thyroglossal cyst	Midline; moves on swallowing AND tongue protrusion; usually subhyoid
Subhyoid bursitis	Midline; moves on swallowing; rare
Lipoma	Does not move on swallowing; soft; lobulated
Dermoid cyst	Midline; tense; does not move on swallowing
Lymph node	Lateral usually; does not move on swallowing unless fixed to trachea

8. MANAGEMENT OVERVIEW

Indications for Surgery in Goitre

Pressure symptoms - dyspnoea, dysphagia, stridor
Cosmetic disfigurement
Suspected or confirmed malignancy
Retrosternal extension
Toxic goitre failing medical management or not suitable for RAI
Failure to respond to medical treatment

Types of Surgery

Procedure	Indication
Hemithyroidectomy (lobectomy + isthmusectomy)	Solitary nodule (diagnostic or therapeutic), Bethesda IV, unilateral disease
Near-total thyroidectomy	Most thyroid cancers, bilateral disease
Total thyroidectomy	Differentiated thyroid cancer >1 cm, medullary thyroid Ca, Graves' disease (surgical option)
Subtotal thyroidectomy	Graves' disease (historical), bilateral toxic MNG
Hartley-Dunhill operation	One lobe + partial contralateral = for bilateral MNG

Medical Management

Antithyroid drugs: Carbimazole, propylthiouracil (PTU)
Beta-blockers: Propranolol - control symptoms (palpitations, tremor) rapidly
Iodine (Lugol's): Pre-op in Graves' to reduce vascularity
Radioactive Iodine (I-131): Graves' disease, toxic MNG (not in pregnancy/children)
Thyroxine: Hypothyroidism post-thyroidectomy; also used to suppress TSH in differentiated Ca
Iodine supplementation: Endemic goitre prevention and treatment

9. COMPLICATIONS OF THYROIDECTOMY (Classic Viva Topic)

Immediate (0-24 hrs)

Complication	Mechanism	Feature
Reactionary haemorrhage	Slipped ligature	Neck swelling, stridor, cyanosis
Respiratory obstruction	Haemorrhage compressing trachea	Emergency - open wound at bedside
Thyroid storm	Excess hormone release	Hyperpyrexia, tachycardia, agitation
RLN injury (unilateral)	Nerve cut/stretched	Hoarseness
RLN injury (bilateral)	Both nerves cut	Aphonia, stridor - re-intubation needed

Early (24 hrs - 1 week)

Complication	Mechanism	Feature
Hypoparathyroidism	Parathyroids removed/devascularized	Hypocalcaemia → tetany; Chvostek's, Trousseau's signs
Wound infection
Tracheomalacia	Chronic pressure on tracheal rings	Post-extubation stridor - "tracheal kiss"

Late

Complication
Hypothyroidism	After total/near-total thyroidectomy → lifelong thyroxine
Recurrence of goitre / toxicity	After subtotal thyroidectomy
Keloid scar
Hypoparathyroidism (permanent)	1-3% after total thyroidectomy
Voice change (external laryngeal nerve)	Loss of high-pitched notes, voice fatigue

Viva trap - "Bed-side emergency kit": Every patient post-thyroidectomy must have a stitch-cutter or clip remover at the bedside to open the wound in emergency to evacuate haematoma.

10. HIGH-YIELD VIVA QUESTIONS & ANSWERS

Q: Why does thyroid swelling move on swallowing? A: The thyroid is enclosed within the pretracheal fascia, which is attached to the trachea and larynx. On swallowing, these structures elevate, carrying the thyroid with them.

Q: What is the difference between primary, secondary, and tertiary thyrotoxicosis?

Primary = Graves' disease (diffuse toxic goitre) - de novo autoimmune
Secondary = Toxic multinodular goitre - pre-existing MNG becomes toxic
Tertiary = Solitary toxic adenoma (Plummer's disease)

Q: FNAC cannot differentiate follicular adenoma from carcinoma. Why? A: Because the distinction requires histological evidence of capsular invasion or vascular invasion, which cannot be assessed on fine needle aspirate cytology.

Q: What is a "cold nodule" and what is its significance? A: A nodule with decreased radionuclide uptake on scintigraphy. Non-functioning. About 10-15% of cold nodules are malignant - hence all cold nodules require FNAC.

Q: What is Berry's sign? A: Absence of carotid pulsation on the side of the thyroid swelling, indicating that the malignant thyroid mass has encircled/enveloped the carotid artery. Strong indicator of malignancy and inoperability.

Q: What is Pemberton's sign? A: Raising both arms above the head causes facial congestion, cyanosis, elevation of JVP and respiratory distress - indicates a retrosternal goitre causing functional obstruction of the thoracic inlet.

Q: What is Kocher's test? A: Lateral compression of the goitre produces stridor - indicates significant tracheal compression.

Q: The most common thyroid cancer is...? A: Papillary carcinoma (~80%). Spreads via lymphatics. Good prognosis. Associated with Psammoma bodies (calcification), radiation exposure, RET/PTC mutations.

Q: Which thyroid cancer has the WORST prognosis? A: Anaplastic carcinoma - median survival ~3-6 months. Usually occurs in elderly. Very rapidly growing, rock-hard mass.

Q: Which thyroid cancer is a marker of MEN syndrome? A: Medullary thyroid carcinoma - associated with MEN 2A (with phaeochromocytoma + hyperparathyroidism) and MEN 2B (with phaeochromocytoma + mucosal neuromas + marfanoid habitus). RET proto-oncogene mutation.

Q: Pre-operative preparation for Graves' disease thyroidectomy? A: (1) Render euthyroid with antithyroid drugs (carbimazole) over 6-8 weeks. (2) Give Lugol's iodine (potassium iodide) for 10-14 days pre-op to reduce gland vascularity and firmness. (3) Propranolol to control sympathetic symptoms.

Q: What is the Hartley-Dunhill operation? A: Total removal of one lobe + isthmus + subtotal removal of the other lobe. Used for bilateral multinodular goitre - balances the risk of recurrence vs hypothyroidism.

Sources: S Das - A Manual on Clinical Surgery 13th ed. | Bailey & Love's Short Practice of Surgery 28th ed. | Sabiston Textbook of Surgery | Schwartz's Principles of Surgery 11th ed. | Harrison's Principles of Internal Medicine 22E

Brest topic in surgery cover the history taking , examination point,and other viva qsn

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Breast - Complete Surgical Viva Guide

1. HISTORY TAKING

Patient Details

Age - single most important demographic factor:
- <35 yrs: Fibroadenoma most likely
- 20-40 yrs: Fibroadenosis (mammary dysplasia)
- 40 yrs: Carcinoma must always be excluded
- Young lactating woman: Mastitis / breast abscess
Sex - rare but carcinoma in males is possible
Residence - carcinoma + fibroadenosis more common in western world; rare in Japan
Parity / Social status - nulliparous women have higher risk of carcinoma and fibroadenosis; breastfeeding is protective

Chief Complaint

1. Lump (most common presenting complaint)

Mode of onset, duration
Rate of growth: slow + long history = benign; fast + short history = likely malignant
Sudden enlargement: haemorrhage into a cyst or nodule
Note: average time between patient discovering a breast lump and reporting to a surgeon is ~6 weeks in carcinoma

2. Pain (mastalgia)

"Carcinoma of the breast is a painless condition." - S Das

Pain type	Diagnosis
Throbbing, severe	Acute mastitis / abscess (pus formation)
Cyclical, worse before periods	Fibroadenosis (most common benign cause)
Non-cyclical, localized	Periductal mastitis, fat necrosis
Back / hip / shoulder pain (late)	Bony metastases from carcinoma
Painless lump accidentally felt	Must rule out carcinoma

3. Nipple Discharge

Discharge colour	Diagnosis
Bright red / blood	Duct papilloma (most common), duct carcinoma
Serous / clear	Duct papilloma, early carcinoma
Green / brown	Fibroadenosis (duct ectasia)
White (milk)	Galactorrhoea (prolactinoma, drugs)
Purulent	Abscess, infected duct ectasia

4. Nipple changes

Retraction / inversion - recent onset = malignancy; lifelong = normal variant
Eczema / scaling of nipple = Paget's disease of nipple (must exclude underlying ductal carcinoma)
Ulceration

5. Skin changes - redness, dimpling, peau d'orange, ulceration, satellite nodules

6. Axillary swelling - may indicate nodal metastases

Past History

Previous breast lumps, biopsies, operations
History of chest wall irradiation (risk factor for breast cancer)
Hormone use - OCP, HRT (risk factors)
Previous carcinoma of the opposite breast or endometrium

Menstrual & Obstetric History

Menarche age (early menarche = risk factor)
Menopause age (late menopause = risk factor)
Pregnancies: nulliparity or first child after 30 = risk factor
Breastfeeding: protective
Last menstrual period

Family History

First-degree relative (mother, sister) with breast cancer = 2-3x increased risk
BRCA1 / BRCA2 mutations (ask for family history of ovarian cancer too)
Bilateral or early-onset (<50 yrs) breast cancer in family = high risk

Drug History

OCP, HRT (slight increased risk)
Phenothiazines, metoclopramide, domperidone → galactorrhoea
Tamoxifen (if currently being treated)

2. EXAMINATION - SYSTEMATIC APPROACH

General Examination

Build, weight loss (late cancer)
Pallor, jaundice (liver metastases)
Lymphoedema of the arm (post-surgery or nodal blockage)
Lumbar spine / hip tenderness (bone metastases)
Hepatomegaly (liver metastases)
Signs of pleural effusion (lung metastases)

LOCAL EXAMINATION

Setup

Patient seated facing examiner, fully exposed to the nipple level
Adequate privacy; chaperone
Examine normal breast first, then compare with affected side

INSPECTION (4 positions)

Position 1: Arms by the side (at rest) Note:

Symmetry of both breasts - any size difference
Contour and shape - any flattening, bulge, distortion
Skin changes:
- Redness / erythema = mastitis, inflammatory carcinoma
- Peau d'orange = skin oedema with pitting, deepening of sweat gland openings - classic sign of carcinoma (lymphatic blockage by cancer cells)
- Dimpling / puckering = invasion of Cooper's ligaments by carcinoma
- Dilated superficial veins = cystosarcoma phylloides, rapidly growing sarcoma, acute duct obstruction
- Ulceration / fungation = advanced carcinoma
- Skin nodules = satellite / metastatic skin deposits
Nipple position, level, symmetry
- Retraction (recent = malignant; central mass pulling nipple)
- Deviation / asymmetry
- Ulceration / eczema = Paget's disease
Axillae - visible swelling, skin puckering

Peau d'orange - classic sign of breast carcinoma with oedematous skin and deepened pores

Peau d'orange - oedema of the skin of the breast with deepening of the sweat gland mouths, due to blockage of subcuticular lymphatics by cancer cells. - S Das Clinical Surgery

Nipple retraction due to breast carcinoma

Nipple retraction caused by deep carcinoma pulling along the lactiferous ducts via fibrosis - S Das

Position 2: Arms raised above the head

Reveals the lower surfaces of both breasts
Brings out lumps, puckering and distortion not visible at rest
Inspect the submammary fold (lift breast if needed)
Inspect axillae for swelling and ulceration

Position 3: Hands pressed on hips (pectoral contraction)

Tenses the pectoralis major
Accentuates dimpling / tethering if present (Cooper's ligament invasion)
Any change in contour with muscle contraction

Position 4: Leaning forward

Pendulous breasts fall forward - reveals asymmetry and skin changes on undersurface

PALPATION

Patient position: Start in sitting, then semi-recumbent (45°), then lying supine with a small pillow under the scapula of the side being examined (prevents breast falling laterally).

Technique:

Use the palmar surface of the fingers with the hand flat (NOT the palm of hand, NOT fingertips)
Palpate between pulps of fingers and thumb to examine a lump
Always palpate the normal breast first to know the baseline texture

Quadrant Examination

Systematically palpate all four quadrants:

Upper outer (UOQ) - most common site of carcinoma (50%)
Upper inner
Lower outer
Lower inner
Retroareolar region (just behind the nipple - easy to miss!)
Axillary tail of Spence

On Finding a Lump - Assess All These Features:

1. Site / Position

Quadrant + distance from nipple
UOQ is most common; retroareolar is often missed

2. Size and Shape

Measure in cm
Globular = fibroadenoma
Irregular = carcinoma

3. Number

Solitary: fibroadenoma, cyst, carcinoma
Multiple bilateral: fibroadenosis

4. Surface

Smooth = fibroadenoma, cyst
Irregular / nodular = carcinoma, fibroadenosis

5. Edge / Margin

Well-defined = fibroadenoma, cyst
Ill-defined / spiculated = carcinoma

6. Consistency

Consistency	Diagnosis
Soft, cystic	Breast cyst, abscess
Firm, India-rubber / diffuse	Fibroadenosis
Firm, well-encapsulated	Fibroadenoma
Stony hard, irregular	Carcinoma
Varies (soft to hard)	Sarcoma / cystosarcoma phylloides

7. Fluctuation - test for cystic swellings (cyst, abscess)

8. Transillumination - in dark room; cyst = translucent; solid tumour = opaque; fat = translucent

9. Tenderness - mastitis, abscess; absent in carcinoma (painless)

10. Fixity to Skin - Three levels:

(i) Tethering to skin: Invasion of Cooper's ligaments (fibrous septae from gland to skin). The lump can still be moved slightly but at the extremes of movement, skin dimples.

Test: move lump side to side - skin dimples at extremes = tethered

(ii) Fixed to skin: Direct infiltration of skin by tumour. Lump cannot be moved independent of skin. Overlying skin cannot be pinched up.

(iii) Note: Any tumour deep to the nipple will be fixed to the nipple (benign or malignant) because the main lactiferous ducts pass through it.

11. Fixity to Breast Tissue

Fibroadenoma: freely mobile within breast substance = "Breast Mouse" / "Floating Tumour"
Carcinoma: fixed to breast tissue; fibrous strands radiating from mass

12. Fixity to Pectoralis Major

Ask patient to press her hand on her hip lightly (muscle relaxed) - test lump mobility
Now ask her to press hip as hard as she can (muscle taut) - retest mobility
Reduced mobility in the line of muscle fibres = fixed to pectoralis major or pectoral fascia

Testing fixity of breast lump to pectoralis major by tightening the muscle

Testing lump fixity to pectoralis major - patient presses hip to tighten muscle, then lump mobility is reassessed in direction of muscle fibres. - S Das

13. Fixity to Serratus Anterior

Lower outer quadrant lumps may fix to serratus anterior
Test: ask patient to push against a wall with outstretched hand of affected side - fixed lump barely moves

14. Fixity to Chest Wall

Lump restricted in ALL directions irrespective of any muscle contraction = fixed to chest wall (T4 carcinoma)

15. Nipple Palpation

Feel tissue just behind the nipple
Press the lump behind the nipple - note if this expresses discharge
Colour of discharge (see above)
From single duct (papilloma) or multiple ducts (fibrocystic)

16. Axillary Examination Patient's arm supported by examiner's ipsilateral hand (relaxing pectoralis) Palpate all groups:

Anterior (pectoral) nodes - most commonly first involved in breast cancer
Central nodes
Posterior (subscapular) nodes
Lateral (brachial) nodes
Apical nodes (infraclavicular)

Note: Size, number, consistency, mobility, tenderness of any palpable nodes

17. Supraclavicular Nodes

Feel in the angle between the clavicle and sternomastoid from behind
Enlarged = advanced (N3) disease

18. Opposite Breast and Axilla - must always be examined

3. DIFFERENTIAL DIAGNOSIS OF A BREAST LUMP

Condition	Age	Consistency	Mobility	Tender	Skin/Nipple	Other
Fibroadenoma	15-35	Firm, smooth	Highly mobile ("breast mouse")	No	Normal	Well-defined, no nodes
Breast cyst	30-55	Cystic/fluctuant	Mobile	No	Normal	Transilluminates; may refill
Fibroadenosis	Any (20-50)	Firm, diffuse, nodular	Diffuse bilateral	Yes (cyclical)	Normal	Multiple lumps
Carcinoma	>40	Stony hard	Fixed to breast tissue	No	Peau d'orange, dimpling	Hard nodes, nipple retraction
Abscess	Lactating	Fluctuant	Fixed (inflamed)	Very tender	Red, warm	Fever, raised WBC
Fat necrosis	Any (post-trauma)	Hard, irregular	May be fixed	±	Skin tethering possible	History of trauma
Cystosarcoma phylloides	>40	Varies; huge	Mobile (initially)	No	Dilated veins; not fixed	Rapidly growing, giant tumour
Duct papilloma	>30	Cystic near areola	Mobile	No	Bloody nipple discharge	Retroareolar
Paget's disease	>50	Underlying mass	-	No	Eczema of nipple	Represents underlying DCIS/Ca
Gynaecomastia (male)	Any	Firm disc	Central	Tender	Normal	Bilateral rubbery disc

4. TRIPLE ASSESSMENT (The Standard for any Breast Lump)

The gold standard is Triple Assessment - all three must be done:

Component	What
1. Clinical examination	History + full breast exam
2. Imaging	Mammogram (<35 yrs: USG; >35 yrs: Mammogram ± USG)
3. Tissue sampling	FNAC (cytology) or Core needle biopsy (histology)

If all 3 are benign = safe to observe. If ANY is suspicious = proceed to excision/surgery.

5. INVESTIGATIONS

Imaging

Mammography

Investigation of choice for women >35-40 years
Two views: craniocaudal (CC) and mediolateral oblique (MLO)
Malignant features: spiculated mass, pleomorphic calcifications, skin thickening, nipple retraction
BIRADS classification: BIRADS 1 = normal; BIRADS 5 = highly suggestive malignancy
Screening mammogram: every 2 years for women 50-74 yrs (national programs)

Ultrasound (USG)

Preferred for women <35 years (dense breast tissue makes mammography less useful)
Distinguishes solid vs cystic lesions
Guides FNAC/core biopsy
Benign features: smooth margins, posterior acoustic enhancement (cyst)
Malignant features: irregular hypoechoic mass, spiculated margins, posterior shadowing

MRI Breast

Not routine; used for:
- BRCA mutation carriers (high-risk screening)
- Assessing extent of lobular carcinoma
- Occult primary breast cancer with axillary nodes
- Pre-operative planning for BCS (breast conserving surgery)
- Implants assessment

Tissue Diagnosis

FNAC (Fine Needle Aspiration Cytology)

22-25G needle, syringe, no anaesthesia
Gives cytological diagnosis only
Reports as: C1 (inadequate) / C2 (benign) / C3 (atypia) / C4 (suspicious) / C5 (malignant)
Advantage: quick, cheap, outpatient
Limitation: cannot distinguish invasive from in-situ cancer; cannot give hormone receptor status

Core Needle Biopsy (Tru-cut)

14-16G needle; gives a core of tissue = histological diagnosis
Can determine: invasive vs in-situ; grade; ER/PR/HER2 status
Preferred over FNAC when preoperative planning is needed

Excision Biopsy

When FNAC/core is inconclusive (Bethesda III equivalent / C3)
Provides definitive diagnosis

Blood Tests

CBC - anaemia in advanced disease
LFT, ALP - liver / bone metastases
Serum calcium - hypercalcaemia in bone metastases
Tumour markers: CA 15-3, CEA - used for monitoring treatment response, not diagnosis
Hormone receptor status (ER, PR, HER2) on biopsy - determines treatment

Staging Investigations (if cancer confirmed)

Chest X-ray - lung metastases
CT chest / abdomen / pelvis - staging
Bone scan - bone metastases (indicated if bone pain or raised ALP)
PET-CT - accurate staging in high-risk disease

6. STAGING OF BREAST CANCER

TNM Classification

T	Description
T1	≤2 cm; no fixation; no nipple retraction
T2	2-5 cm; skin may be tethered; no pectoral fixation
T3	>5 cm; skin fixed or ulcerated; pectoral fixation
T4	Chest wall fixation; peau d'orange over large area; inflammatory carcinoma

N	Description
N0	No palpable ipsilateral nodes
N1	Mobile ipsilateral axillary nodes
N2	Fixed axillary nodes
N3	Supraclavicular / infraclavicular nodes; arm oedema

M	Description
M0	No distant metastasis
M1	Distant metastasis present

Clinical Stages (S Das)

Stage I: Growth limited to breast; ± small skin adherence
Stage II: + Mobile axillary nodes; ± slight pectoral tethering
Stage III: Fixed to pectoral muscle; skin involvement > tumour size
Stage IV: Fixed to chest wall; fixed axillary nodes; supraclavicular nodes; distant metastases

7. TYPES OF BREAST CARCINOMA

Type	Features
Scirrhous carcinoma	Most common; very hard, fibrotic; slow growing; infiltrative
Atrophic scirrhous	Least malignant; very slow growing; may mimic benign
Encephaloid (Medullary)	Soft brain-like; rapidly growing; less fibrosis; better prognosis
Comedocarcinoma	Intraductal; DCIS type; "toothpaste-like" plugs from ducts
Colloid (Mucinous)	Gelatinous; better prognosis; older women
Mastitis carcinomatosa (Inflammatory Ca)	Most malignant; entire breast red, hot, oedematous; no palpable lump; poor prognosis
Paget's disease of nipple	Eczema-like change of nipple; underlying DCIS or invasive Ca; always biopsy
Lobular carcinoma	Diffuse, bilateral; harder to detect on mammogram

Metastatic spread:

Lymphatic: Axillary nodes (most common) → supraclavicular → internal mammary nodes
Blood: Bones (most common - especially spine, pelvis, femur), lung, liver, brain, ovary (transcoelomic)

8. MANAGEMENT

Benign Conditions

Condition	Management
Fibroadenoma	Small (<3 cm): observe; large / growing / symptomatic: excision
Breast cyst	Aspiration (diagnostic + therapeutic); if bloody fluid / residual lump → biopsy
Fibroadenosis	Reassurance; evening primrose oil; danazol for severe mastalgia
Mastitis / Abscess	Antibiotics (flucloxacillin); if abscess = incision and drainage (I&D) or needle aspiration
Duct papilloma	Microdochectomy (excision of affected duct); considered premalignant
Cystosarcoma phylloides	Wide local excision or simple mastectomy (tends to recur); rarely malignant
Gynaecomastia	Treat cause; if persists / painful: subcutaneous mastectomy

Malignant Conditions - Breast Cancer Surgery

Breast Surgery Options

Procedure	Indication
Wide Local Excision (WLE) / Lumpectomy	Early cancer; followed by radiotherapy = Breast Conserving Surgery (BCS)
Quadrantectomy	Removal of involved quadrant
Simple (Total) Mastectomy	Carcinoma in-situ; prophylactic (BRCA1/2); when BCS not possible
Modified Radical Mastectomy (MRM)	Most common surgery for breast cancer today; removes breast + axillary nodes; preserves pectoralis major
Radical Mastectomy (Halsted)	Historical; removes breast + pectoralis major + minor + axillary nodes; rarely done now
Extended Radical Mastectomy	Also removes internal mammary nodes; obsolete

Axillary Management

Procedure	Indication
Sentinel Lymph Node Biopsy (SLNB)	Clinically node-negative axilla; if SLNB negative = no further axillary surgery
Axillary Lymph Node Dissection (ALND)	SLNB positive; clinically / radiologically positive nodes

Adjuvant Therapy

Treatment	Indication
Radiotherapy	Post-BCS (mandatory); post-mastectomy in high-risk; chest wall
Chemotherapy	Triple-negative, HER2+, high-grade, node-positive disease
Hormonal therapy (Tamoxifen / Aromatase inhibitors)	ER/PR positive (5-10 years)
HER2 targeted (Trastuzumab/Herceptin)	HER2-positive tumours

9. HIGH-YIELD VIVA QUESTIONS & ANSWERS

Q: What is the most common site of carcinoma in the breast? A: Upper outer quadrant (UOQ) - approximately 50% of all breast carcinomas. It has the greatest volume of breast tissue and the axillary tail.

Q: What is "peau d'orange" and what causes it? A: Peau d'orange (French: "skin of an orange") is oedema of the breast skin with deepening of the sweat gland and hair follicle openings, giving an orange-peel appearance. It is caused by obstruction of the subcuticular lymphatics by cancer cells, leading to skin oedema, while the tethered skin over follicles cannot expand - creating the pitted appearance.

Q: What is Cooper's ligament and what happens when it is invaded? A: Cooper's ligaments (suspensory ligaments of the breast) are fibrous septae passing from the glandular breast tissue to the overlying skin. When invaded by carcinoma, they become shorter and inelastic, pulling the skin inwards, causing skin dimpling, puckering or retraction.

Q: What is a "breast mouse"? A: A fibroadenoma - it is highly mobile within the breast substance and freely movable under the examining fingers, hence the term. It is NOT fixed to the skin or deeper structures.

Q: What is Paget's disease of the nipple? A: A form of breast cancer presenting as eczema-like changes (scaling, weeping, crusting) of the nipple and areola. It represents extension of an underlying ductal carcinoma in-situ (DCIS) or invasive carcinoma through the lactiferous ducts to the nipple epidermis. Always biopsy nipple eczema in a woman over 40. Treatment: total mastectomy or BCS + nipple excision + radiotherapy.

Q: "Breast cancer is painless" - always true? A: Painless at onset - all neoplasms of the breast (benign or malignant) are painless to start. However, late-stage carcinoma can cause pain from bone metastases (back, hip, shoulder pain). Inflammatory carcinoma is a painful exception. Pain should never be used to exclude carcinoma.

Q: What is the most common type of breast cancer? A: Invasive ductal carcinoma (IDC) / scirrhous carcinoma - accounts for ~75-80% of all breast cancers. Presents as a hard, stony, irregular mass with fibrous stroma.

Q: What is the difference between tethering and fixation to skin?

Tethering: Malignancy has spread to Cooper's ligaments; lump can still move independently through a small range, but skin dimples at the extremes of movement. (T2 feature)
Fixed: Direct infiltration of skin by tumour; lump cannot be moved independently at all; overlying skin cannot be pinched up. (T4 feature)

Q: What is triple assessment? A: The gold standard approach for evaluating any breast lump:

Clinical examination
Imaging (mammogram ± ultrasound)
Tissue sampling (FNAC or core biopsy) All three results must be concordant. If any one is suspicious → proceed to surgery.

Q: How do you test for fixity to pectoralis major? A: Ask the patient to press her hand on her hip (muscle relaxed) - assess lump mobility. Then ask her to press as hard as possible (muscle taut) - retest mobility in the line of the muscle fibres. Restricted mobility with the muscle contracted indicates fixity to pectoralis major or pectoral fascia.

Q: What is Modified Radical Mastectomy (MRM)? A: Removal of the entire breast + all axillary lymph nodes, while preserving both pectoralis major and minor. This is the standard surgical procedure for breast cancer today. It replaced Halsted's radical mastectomy (which removed both pectoral muscles) as outcomes were equivalent with less morbidity.

Q: Most common site of blood-borne metastasis from breast cancer? A: Bones (spine, pelvis, femur) - most common. Others: lungs, liver, brain, ovary (Krukenberg - transcoelomic).

Q: Risk factors for breast cancer? A: MNEMONIC - "FEMALE BRAS"

Family history (first-degree relative, BRCA1/2)
Early menarche (<12 yrs)
Menopause late (>55 yrs)
Age (>40 yrs)
Late first pregnancy / nulliparity
Exposure to radiation
Body weight (obesity - increases oestrogen)
Risk from HRT / OCP
Alcohol, diet rich in saturated fat
Socioeconomic (more in Western world)

Q: What is inflammatory carcinoma? A: The most malignant type of breast cancer (mastitis carcinomatosa). The entire breast becomes red, hot, swollen, oedematous - resembling acute mastitis. There may be no discrete palpable mass. Due to massive lymphatic infiltration causing dermal lymphatic obstruction. Very poor prognosis. Treatment: neoadjuvant chemotherapy first, then surgery + radiotherapy. Do NOT mistake it for mastitis and delay diagnosis.

Sources: S Das - A Manual on Clinical Surgery, 13th ed. | Bailey & Love's Short Practice of Surgery, 28th ed. | Schwartz's Principles of Surgery, 11th ed. | Harrison's Principles of Internal Medicine, 22E

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