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GS67 General and Thoracic Surgery Toronto Notes 2023

Diagnostic Procedures

•

"

triple test "

for diagnosis of breast cancer:

• clinical breast exam

imaging

>30 yr: mammography and U/S

<30 yr or lactating or pregnant: U/S (high breast density)

pathology ( biopsy)

U/S or mammography guided core needle biopsy:most common

needle aspiration: for palpable cystic lesions;send fluid for cytology if blood or cyst does not

completely resolve

excisional biopsy: only performed assecond choice to core needle biopsy;should not be done

for diagnosis if possible

Genetic Screening

• consider testing for BKCAI/2 if:

• young patient (<35 yr)

bilateral breast cancer in patients <50 yr

patient diagnosed with breast AND ovarian cancer

• strong family history of breast/ovarian cancer

family history of male breast cancer

Staging

patients are assigned a clinical stage preoperatively (cl'

NM);following surgery the pathologic stage is

determined (plNM)

• clinical

tumour size by palpation, mammogram, U/S, and/or MR1

nodal involvement by palpation, imaging

metastasis by physical exam, CXR, abdominal U/S (orO'

chest/abdomen/pelvis), and bone scan

(usually done postoperative if node-positive disease)

• pathological

• tumour size and type

grade: modified Bloom and Richardson score (1 to 111) - histologic, nuclear, and mitotic g

• number of axillary nodes positive for malignancy out of total nodes resected, extranodal

extension, and SLNB positive/negative

tumour biology: estrogen receptor (ER), progesterone receptor ( HR), and HER2/neu oncogene

status

margins:for invasive breast cancer, negative margin issufficient;for DC1S prefer 2 mm margin

lymphovascular invasion (LV1)

extensive in situ component (E1C):DC1S in surrounding tissue

involvement of dermal lymphatics (inflammatory) - automatically Stage Illb

Phyllodes tumours are rare

flbroepithelial breast tumouisthat can

be benign or malignant that mostly

affect women from 35-55 yr

rade

Table 30. TNM Classification System for Staging of Breast Cancer (AJCC 2017)

Unfavourable

Features

Favourable

Features

Primary Tumour (T) Regional Lymph Nodes ( N) Distant Metastasis ( M)

TX Primary lumout cannot be assessed

10 No evidence of primary tumour

tis Ductal carcinoma insitu

NX Regional lymph nodes cannot be assessed MO Ho dislanl metastasis

NO No regional lymph node metastasis

HI Involvement ol 1-3 axillary lymph nodes

and/or clinically negative internal

mammary nodes on sentinel node biopsy

• "

2 cm

• Grade I (low

grade)

• Node

negative

• ER positive

• Mucinous

pattern

•

»5cm

• Grade III (high grade)

• Node positive

• ER negative

• Inflammatory cancer

• Her2i'Neu positive

• Positive maigins

• lymphovascular

invasion

• Epidermal indusion

Ml Distant metastasis

11 Tumour s2 cm in greatest dimension

N 2 Involvement ol 4-9 axillary lymph nodes or clinically

positive ipsilateral internal mammary lymph node

12 Tumour >2cm but <5 cm in greatest dimension

T3 tumour >5 cm in greatest dimention

T4 Tumour of any size with direct extension to chest wall

and/or skin

cyst

• Dermal lymphatics

involved

Pathology

Analysis of Circulating Tumour DNAto Monitor

Metastatic Breast Cancer

NEJM 2013:368:1199 1209

Study: i i : in • : ok

, . . '

ONA, lancer anbgei 15- 3 (CA 15 3).and circulating

tumour celsin 30 women with metastatic breast

cancel leceiving systemic therapy.Ihe results were

compaied with radiographic imaging of tumours.

Results/Conclusions:Circulating tumour DNA was

detected in 97% ot women and showed greater

correlation with changes in tumour burden than did CA

15-3 nr circulating tumourcells. proving the earliest

measure of treatment response in 53 » of women.

CA15-3and circidatng tumourcellswere detected

in 78% and 81% at women,respectively.Circulating

tumour ONA may therefore he an informative

biomarker for metastatic breast cancer.

NON-INVASIVE

Ductal Carcinoma in situ (DCIS)

• proliferation of malignant ductal epithelial cells completely contained within breast ducts,often

multifocal

• 80% non-palpable; detected by screening mammogram as microcalcifications

• risk of invasive ductal carcinoma in same breast up to 35% in 10 yr

• treatment

lumpectomy with wide excision margins + radiation (5-10% risk of invasive cancer)

mastectomy if large area of disease, high grade, or multifocal (risk of invasive cancer reduced to

1%)

possibly tamoxifen as an adjuvant treatment

99% 5 vr survival

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GS68 General and Thoracic Surgery Toronto Notes 2023

Lobular Carcinoma in situ (LCIS)

• neoplastic cells completely contained within breast lobule

• no palpable mass and no mammographic findings; usually incidental finding on breast biopsy for

another indication

• LCIS is a risk factor for invasive carcinoma (approximately 1%/yr)

• treatment

if diagnosed on core biopsy, excisional biopsy necessary to rule out malignancy

• if diagnosed on excisional biopsy, wide excision not needed since LCIS is often multicentric and

not managed as precursor lesion

clinical follow-up and surveillance; consider chemoprevention (e.g. tamoxifen)

10 Year Survival after ItmlConstning Surgery

Plus Radiotherapy Comparrdwith Mastectomy

i it tally Breast Cancer in hit Metherlaads: A

Population-Based Study

Lancet Oncol 201G;17(8|:11S8

See landmark General and Thoracic Surgery Trials

table for mnre Wormation on tie10-year sanriral

alter breast-conserving surgery plus rai otherapy

compa red with mastectomy in early breast cancer.

INVASIVE

Invasive Ductal Carcinoma (most common 80%)

• originatesfrom ductal epithelium and infiltrates supporting stroma

• four types: tubular, mucinous, medullary, and inflammatory

• characteristics: hard,scirrhous, inliltrating tentacles, and gritty on cross-section

• divided into three grades based on cytologic and architectural features: well differentiated (grade

1), moderately differentiated (grade 2), poorly differentiated (grade 3)

Invasive Lobular Carcinoma (8-10%)

• originatesfrom lobular epithelium, 20% bilateral

• subtle thickening originating from lobes/lobules; usually positive for estrogen and progesterone

receptors

• harder to detect on mammography due to lack of microcalcifications (may benefit from MR1)

Paget’s Disease of the Breast (1-3%)

• ductal carcinoma that invades nipple with scaling, ulceration, erythema, and eczematouslesion

Inflammatory Carcinoma (1-3%)

• most aggressive form of breast cancer

• ductal carcinoma that grows in nests (vs.solid tumour);invades and blocks dermal lymphatics

• clinical features: erythema,skin edema, warm,swollen, and tender breast ± lump, nipple changes

• peau d orange indicates advanced disease (Illb-IV)

Sarcomas:rare

• most commonly phyllodes tumour, a variant of fibroadenoma with potential for malignancy

• can also be angiosarcomas- after previous radiation

Lymphoma:rare

Other

• papillary'

, medullary, mucinous, and tubular cancers

• generally better prognosis

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GS69 General and Thoracic Surgery Toronto Notes 2023

Treatment

Table 31. Breast Cancer Treatment by Stage

Stage Primary Treatment Options Adjuvant Systemic Therapy

BCS * radiotherapy

BCS alone il margins >1cm and low nuclear grade

Mastectomy * » SLMB

8CS * axillary node dissection •radiotherapy

Mastectomy*

’

axillary node dissection/SIN 6

Consider postoperative tamosilen lor ER*. Iraslurumab lor

HER 2-*

0 [in situ)

lis. NO, MO

May not be needed; discuss rislrs/benelits of chemotherapy

and tamoxifen

I

IA: T1. MO. MO

IB:11, N1ml, MO

BCS > axillary node dissection * radiotherapy

Mastectomy* axillary node dissection/SLNB

Chemotherapy lor premenopausal women or

postmenopausal and ER negative,followed by tamoxifen

if ER

-

II

A:10. N1. M0

11. N1, MO

12. NO. MO

8:12. N1, MO

13. NO. MO

III likely mastectomy - axillary node dissection +

radiotherapy after chemotherapy (neoadjuvanl)

Neoadjuvant therapy should be considered (i.e.preoperative)

especially if not resectable chemotherapy and/or hormone

therapy.Adjuvant radiation and chemotherapy may also be

appropriate (i.e. postoperative)

A:10. N2.M0

11. N 2, MO

12. N 2. M 0

13. N1. M0

13. N 2. MO

6:14, NO, MO

14. N1. M0

I4. N 2. M 0

Inflammatory Mastectomy * axillary node dissection radiotherapy

Surgery as appropriate lor local control

Neoadjuvant therapy

Primary treatment Is systemic therapy (i.e.chemotherapy)

and/or hormone therapy

IV

any 1, any N. Ml

BCS - breast conserving surgery: SLNB •sentinel lymph node biopsy

'llno reason to select mastectomy,the choice betwvcnBCS •radiotherapy andmastectomy can be made according to paUenl s preference since

choice ollocal treatment does not significantly affect survival If local control Is achieved

PRIMARY SURGICAL TREATMENT

Breast Conservation Surgery (BCS)

• lumpectomy must be combined with radiation for survival equivalent to mastectomy

• contraindications include

• high-risk of local recurrence (e.g. extensive malignant-type calcifications on mammogram), and

multifocal primary tumours

failure to obtain tumour-free margins after re-excision

not suitable for radiation therapy (pregnancy, previous radiation, and collagen vascular disease)

• large tumour size relative to breast

BCS can be offered to most women with

stageI/ll disease

There is no survival benefit of

mastectomy over lumpectomy plus

radiation for stageIand II disease

Mastectomy

• radical mastectomy (rare): removes all breast tissue,skin, pectoralis muscle, and axillary nodes

• modified radical mastectomy (MRM):removes all breast tissue,skin, and axillary nodes

• simple mastectomy: removes all breast tissue and skin

• see Plastic Surgery. PL38 for breast reconstruction

Sentinel Lymph Node Biopsy (SLNB)

• performed in women with clinically node-negative invasive breast cancer and those with extensive

DGIS who are undergoing mastectomy

• patients with clinically suspicious nodes should get U/S i I

'

NA prior to decision to proceed with SLNB

• technetium-99 ± blue dye injected at tumour site prior to surgery to identify sentinel node(s)

• intraoperative frozen section evaluated can be considered

• proceed with A1.N1)

if >3 positive nodes, with 1 -3 nodes whole breast radiation therapy maybe an

alternative

• 5% false negative rate

Axillary Lymph Node Dissection (ALND)

• perform in patients with:

locally advanced (T4a, b, c) or inflammatory breast cancer

clinically node-positive axilla, confirmed by INA or core biopsy, in a patient for whom

neoadjuvant chemotherapy is not planned

• several other specific cases (sentinel or axillary nodes, which remain positive after neoadjuvant

chemotherapy, axillary recurrence following previous breast cancer treatment, among others)

• side effects: risk of arm lymphedema (10-15%),especially if getting radiation therapy, decreased arm

sensation, and shoulder pain

Effect of Radiotherapy after Mastectomy and

Axillary Surgery on 10 Tear Rccurience aad 20

Yeai Breast Cancer Mortality: Meta-Analysis ol

Individual Patient Data for 8135 Women in 22

Randomised Trials

EBCICG (Early Breast Cancel lilalists'Collaborative

Group)

lancet 2014; 383|993S|:2127-2135

Study:Assessed the elied of radiotherapy <t

women with one to three positive lymph node alter

mastectomy and an lary dissection ina meta - analysis

o!8135 women in 22 trials.

Results:for 300 women with axillary detection

and no positive nodes,radiotherapy had no

significant effect on local tegional recurrence, overall

recurrence,or breast cancer mortality.For 1314

women with axillary dissection and one to three

positive nodes, radiotherapy reduced local regional,

overall recurrence, and breast cancer mortality.1133

of these 1314 women were in trialsin which systemic

therapy (cyclophosphamide, methotrexate,and

fluorpjtacj . ot tamoxifen) was given in both tiial

groups and radiotherapy again reduced local regional

recurrence,overall recurrence, and breast cancer

mortality,for1732 women with axillary dissection

and four ocmoie positive nodes, radiotherapy

reduced local regional recurrence,overall recurrence,

and breast cancer mortality.

Conclusion:Post mastectomy and axillary

dissection, radiotherapy reduced both recurrence

and bieast cancer mortality in the women with one to

three positive lymph nodes in these trials even when

systemic therapy was given.

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GS70 General and Thoracic Surgery Toronto Notes 2023

ADJUVANT/NEOADJUVANT

Radiation

• indications

decrease risk of local recurrence; almost always used after BCS,sometimes after mastectomy

• inoperable locally advanced cancer

• axillary nodal radiation may be added if nodal involvement

Effect of Axillary Dissection vs.No Axillary

Dissection on 10-Year OverallSurvival Among

Women With Invasive Breast Cancer and Sentinel

Node Metastasis:The ACOSOG 20011 (Alliance)

Randomized Clinical Trial

JAMA 2017;318(10):918-926

Purpose:Assessed whether the10 yr overall survival

of patients with sentinel lymph node metastases

treated with breast-corserr ng therapy and sentinel

lymph node dissection (SIND) alone without axillary

lymph node dissection (AUDI is non inferior to that of

women treated with axillary dissection.

Results:The 10 yr overall survival was 86.3% in

the SLND alone group and 83.6% in the ALNO group.

The 10 yr disease-free survival was 80.2% in the

SUD alone group and 28.2% in the ALNO group.10

yr regional recurrence did not differ significantly

between the 2 groups.

Conclusion:Among women with T1or12 invasive

primary breast cancer, no palpable aitllary

adenopathy,and 1or 2 sentinel lymph nodes

containing metastases.10-yr overallsurvival foe

patients treated with SIND alone was noninferiot to

oveiall survivalfor those treated with ALNO.

Hormonal

• indications

• ER positive plus node-positive or high-risk node-negative

selective estrogen receptor modulators (SERM) if premenopausal (e.g. tamoxifen) or aromatase

inhibitors if postmenopausal (e.g. anastrozole); optimal duration 5-10 yr

• other options include ovarian ablation (e.g. goserelin/GnRH agonist, oophorectomy), progestins

(e.g. megestrol acetate), and androgens (e.g. fluoxymesterone)

• palliation for metastatic disease

Chemotherapy

• indications

ER negative plus node-positive or high-risk node-negative

• triple-negative disease (ER/PR and HER2-negative) - more common in younger and AfricanAmerican women

• ER positive and young age

stage 1 disease at high-risk of recurrence ( high grade,lymphovascular invasion )

• palliation for metastatic disease

• for HER2 positive breast cancer, add trastuzumab ± pertuzumab to the chemotherapy regimen

FOLLOW-UP

Post-Treatment Follow-Up

• assessment and physical exam q3-6 mo x 3 yr, q6-12 mo x 2 yr, and annually thereafter

• following BCS mammography q6- 12 mo; can reduce to annual once stable, no other routine imaging

unless clinically indicated

• women who receive tamoxifen should have regular gvnaecologic follow- up (increased risk of

endometrial cancer)

Local/Regional Recurrence

• recurrence in treated breast or ipsilateral axilla

• 1% per yr up to maximum of 15% risk of developing contralateral malignancy

• 5x increased risk of developing metastases

Metastasis

• bone > lungs > pleura > liver > brain

• treatment is palliative: hormone therapy, chemotherapy, radiation

• overall survival of metastatic breast cancer is 36-60 mo

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GS71 Genera!and Ihorack Surgery Toronto Notes 2023

Surgical Endocrinology

Thyroid and Parathyroid

• see Endocrinology. E24

Thyroidectomy

• indications:some thyroid cancers or suspicious thyroid nodules, metastases to thyroid,large

(substernal) or symptomatic thyroid goitre, toxic nodules, or some patients with Graves’

disease (not

candidatesfor RA1)

• preoperative workup:thyroid U/S for thyroid nodules, ENA for nodules >1 cm with suspicious U/S

features or for most nodules >1.5 cm with low suspicion U/S features, and Cl'

neck for preoperative

staging when advanced disease issuspected

• complications

• lobectomy: recurrent laryngeal nerve palsy (hoarseness or swallowing issues), neck hematoma

total thyroidectomy:same as above plus hypoparathyroidism/hypocalcemia, bilateral RLN palsy

(requiring tracheostomy)

20-75% of patients need thyroxine after lobectomy and 100% need thyroxine after total

thyroidectomy

Parathyroidectomy

• elevated calcium found for any reason as an outpatient (but also incidental finding asinpatient) is

likely primary hyperparathyroidism and should be investigated further

• indications:symptomatic primary hyperparathyroidism (osteoporosis/stones), asymptomatic

primary hyperparathyroidism with specific laboratory criteria (profoundly elevated serum Ca2+,

hypercalciuria/asymptomatic kidney stones, Cr clearance <30% normal, <50 yr)

• contraindications: familial hypocalciuric hypercalcemia

• preoperative localization to find parathyroid adenoma. Localizing studies include:99mTc sestamibi

scanning with ± SPLCT, U/S, contrast CT

• complications: recurrent/superior laryngeal nerve injury, postoperative hypocalcemia,infection, and

bleeding

Adrenal Gland

•see Endocrinology, E35 and E40

•functional anatomy

• cortex:glomerulosa (mineralocorticoids), fasciculata (glucocorticoids), and reticularis(sex

steroids)

medulla:catecholamines (epinephrine, norepinephrine)

•types of adrenal tumours:functional (e.g. Cushing’

s syndrome, Conn’

s syndrome,

pheochromocvtoma) or non-functional

INCIDENTALOMA

•adrenal mass discovered by investigation of unrelated symptoms/issues

Epidemiology

•benign adenoma (70-80%) > metastases to adrenal (22%) »cyst carcinoma,pheochromocvtoma,

neuroblastoma

•metastasis to adrenal gland from:lung > breast, colon, lymphoma, melanoma, and kidney

•peak incidence of carcinoma:females ages 50-60, risk decreases with increasing age and male gender

Investigations

•CT:size >4-6 cm isbest predictor of primary adrenal carcinoma (92% are >6 cm), MRI is not as good

as CT and does NOT need to be done after CT

•functional studies

pheochromocvtoma:plasma metanephrines (highly specific and sensitive).If not available, 24 h

urine catecholamines

Cushing’

s:24h urine cortisol or 1 mg overnight dexamethasone suppression test

• aldosteronoma:electrolytes, AM aldosterone, AM plasma renin activity level, ARR (AldosteroneRenin-Ratio). If inconclusive,saline suppression test if appropriate

not routinely - only if clinical suspicion: adrenal androgens: 17-OH progesterone and

dehydroepiandrosterone (DHEAS)

•ENA biopsy: NOT APPROPRIATE in most cases. Diagnostic adrenalectomy by high volume endocrine

surgeon ideal if diagnostic uncertainty

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GS72 General and Thoracic Surgery Toronto Notes 2023

Treatment

• functional tumour: resect

• non-functional tumour

>4 cm:consider resection

• <4 cm:follow-up imaging in 6-12 mo, resect if >1 cm enlargement

genetic testing important for ALL Pheochromocytoma/paragangliomas as >30% are related to

genetic syndrome

Pancreas

INSULINOMA

• tumour that secretes insulin

• most common pancreatic endocrine neoplasm; 10% associated with MENI syndrome

Clinical Features

• Whipple'

s triad

• palpitations, trembling, diaphoresis, confusion,seizure, and personality changes

Investigations

o

• blood work: decreased scrum glucose and increased serum insulin and (.

'

-peptide, pro-insulin

• CT, HUS, MKI:insulinomas evenly distributed throughout head, body, tail of pancreas

Whipple'

s Triad

• Symptomatic fasting hypoglycemia

• Serum glucose <2-8 mmol/l

• Relief of symptoms when glucose is

administered Treatment

• only 10% are malignant

• enucleation ofsolitary insulinomas may be done endoscopically

• tumours >2 cm located close to the pancreatic duct may require pancreatectomy or

pancreaticoduodenectomy Zollinger-Ellison Syndrome

Characterized by gastric acid

hypersecretion caused by secretion

of gastrin from gastrinomas: patient

experiences diarrhea and abdominal

pain,as well as peptic disease and reflux

disease

GASTRINOMA

• tumoursecreting gastrin;cause of Zollinger-Ellison syndrome,associated with MEN1

Clinical Features

• abdominal pain, PUD,severe esophagitis

• multiple ulcersin atypical locations refractory to antacid therapy

Investigations

• blood work:serum gastrin levels (usually >1000 pg/mL),secretin stimulation test

• endoscopy:90% of patients develop peptic ulcers

• CT,EUS, MRI:70-90% found in Passaro’striangle (head of pancreas medially, 2nd portion of

duodenum inferiorly,and the confluence of the cystic and CBD superiorly)

• somatostatin receptor scintigraphy scan

Hypertrophic Pyloric Stenosis

Non-bilious emesis in infants isthe

classic presentation

Treatment

• 50% are malignant

• surgical resection of tumour dependent on location

• non-surgical treatment:high dose PPI, octreotide (somatostatin analogs)

• radiation therapy may be considered for nonsurgical candidates

Rule of 2sfor Meckel's Diverticulum

• 2% of the population

• 2:1 male-tofemale ratio

• Symptomatic in 2% of cases

. Found within 2 feet (10-90 cm) of the

ileocecal (1C) valve

• 2 inches in length

• 2 inches in diameter

• 2 types of tissue (ileal or ectopic

gastric, pancreatic)

• Often present by 2 y/o

VASOACTIVE INTESTINAL PEPTIDE-SECRETING TUMOUR

• tumoursecreting VIP; commonly located in the distal pancreas and most are malignant when

diagnosed

Clinical Features

• severe watery diarrhea causing dehydration, anorexia, weakness, and electrolyte imbalance

(hypokalemia)

Investigations

• blood work:serum VIP levels

. CT, MRI, EUS

Treatment

• repletion of fluid and electrolytes

• somatostatin analogues

• surgical resection/palliative debulking LJ

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GS73 General and Thoracic Surgery Toronto Notes 2023

Paediatric Surgery

Clinical Features Physical Exam Investigations Treatment

and History

Condition Epidemiology and Pathophysiology

Risk Factors

Prognosis

U/S if suspect

pathology

t-2%oflivebvths

Majority resolve

spontaneousbylyr

MF-61

Prematurity

Communicating hydroceles: Painless scrotaImass Transiilummalion

processus vaginalis connects Communicating suggests

peritoneumwithtunica hydroceles increase hydrocele

vaginalis, so peritoneal fluid in sire with standing Silk glovesign:

flows freety between the two or valsalva,may be gentlypupating

with potential for abdominal absent in the morning hydroceiesac

contents to enter groin (Le. and large inthe overpubic

inguinal hernia) evening tubercle feels

Noncommunicatinghydroceles:

processus vaginalis isclosed

and more fluid produced

than absorbed in tunica

vaginalis:inolder children,

may be secondary to testicular

pathology (e.g.reactors

hydrocele)

Most resolve spontaneously *

2%recurrence

bylyr

Surgical repair if:

Persistence »2 yr

Hydrocele

(seetl'ology.U32)

Pain

Fluctuatingin sire which

suggests communication

Cosmetic reasons

like rubbingsilk Infection

on silk

Hypertrophic

PyloricStenosis

0.031.Che of live Acquired pyloric circular Projectile non-bilious Smooth oblong

muscle hypertrophy results in vomiting T2cm“olive"

gastric outlet obstruction Vomiting 30-60 min mass palpable

Hypovolemia causedby emesis after feeds above umbilicus

Electrolytes (assess Fluidresuscitate with NS. Pytoromyotomy

hypochloremia. correct electrolyteand acid,1

curative

dehydration) base abnormalities with

U/S showspyloric OS.V2MS * 20mEqilKCI at

length17 mm.musde maintenance rate

thickness >4 mm NG lube decompression

UpperGI series

(necessary only when

U/S is unavailable or

non-diagnostic)will

show “stringsip"

births

Can present at

I20 wk.most

commonly at 6 8 wk ol gastric contents causes

hypochloremic,hypokalemic

metabolic alkalosis

Electrolyte exchangebased

volume retention inkidneys

results In paradoxical acitfciria

Hungry after vomiting intheSUQ

Dehydration (variable Visible left toseverity)

M:F-4:1