Surgical Oncology including Breast and Endocrine
Core concepts
Breast and endocrine oncology questions test staging, biology, and treatment sequencing. For breast cancer, know clinical and pathologic staging, receptor status (ER, PR, HER2), grade, and margins. Breast-conserving therapy requires clear margins-no tumor on ink-and adjuvant whole-breast radiation; mastectomy is offered for multicentric disease, prior chest radiation, inability to achieve clear margins, or patient preference. Sentinel lymph node biopsy is standard for clinically node-negative invasive cancer; axillary dissection is reserved for clinically positive nodes or failed mapping in many settings. Neoadjuvant chemotherapy is used for locally advanced disease, inflammatory breast cancer, and selected HER2-positive or triple-negative tumors. Endocrine therapy depends on receptor status and menopausal state.
For thyroid nodules, ultrasound risk features guide fine-needle aspiration; Bethesda category determines surgery versus observation. Papillary thyroid cancer spreads via lymphatics, follicular via hematogenous routes, medullary is associated with calcitonin and MEN syndromes, and anaplastic is aggressive. Primary hyperparathyroidism is usually due to a single adenoma; localization with ultrasound and sestamibi helps before reoperation. Pheochromocytoma requires alpha blockade before beta blockade to avoid hypertensive crisis.
Traps
Do not equate tumor size with nodal status. Inflammatory breast cancer is a clinical diagnosis with skin changes, not simply a large tumor. Paget disease may mimic eczema. Not every thyroid cancer needs total thyroidectomy and radioiodine. In pheochromocytoma, starting a beta blocker first can precipitate crisis.
Worked example
A 55-year-old has a 1.8-cm ER-positive, HER2-negative breast cancer and a clinically negative axilla. She chooses breast conservation. Obtain clear margins, perform sentinel node biopsy, and plan radiation plus endocrine therapy. Rule of thumb: treat the axilla according to clinical nodal status and mapping results, not simply tumor size.