Professor’s Pearls: Surgical Oncology

Professor’s Pearls: Surgical Oncology




Section Review


Consider the following clinical problems and questions posed. Then refer to the professor’s discussion of these issues.


1) A 40-year-old female has a 3-month hx of weight loss and early satiety. She recently developed chills, night sweats, and a rash. What are your diagnostic considerations?

2) A 38-year-old female has a palpable right breast mass found by her primary care physician in the upper outer quadrant on her annual physical examination. The mass is irregular, firm, and fixed. She has no pain or tenderness. Her mother and two maternal aunts died of breast cancer. The patient had a breast biopsy 10 years ago on the same side for “something that was not cancer.” How would you treat this patient?

3) A 57-year-old female is noted to have persistent hypercalcemia (12.5 g/dL) due to primary hyperparathyroidism. She has no comorbidities. Parathyroidectomy has been recommended. How should she be evaluated?

4) A 64-year-old white male farmer presents with an asymptomatic, pigmented upper back lesion that has increased in size and changed color since his wife initially recognized it 2 years ago. Physical examination is significant for a single small, raised, and variably pigmented upper back lesion with irregular borders. Labs demonstrate normal WBC count, hemoglobin, and coagulation studies. Chest radiography reveals cardiomegaly and pulmonary hyperinflation without evidence of pulmonary nodules. How would you proceed in your evaluation?

5) A 72-year-old woman is sent by her primary care physician with a dx of breast abscess. She has no hx of prior breast problems, no abnormal mammograms, and no family hx of breast cancer. She reports that a mass appeared 2 weeks ago and has become inflamed and tender, and a course of antibiotics prescribed by her physician has not helped the situation. On physical examination, the breast is tender and erythematous in the upper inner quadrant, with nondiscrete fullness in the area.

6) A 62-year-old male with long-standing GERD presents with dysphagia. His symptoms have been poorly controlled with intermittent proton pump inhibitor usage. He has trouble with solids and occasionally with liquids. What are the diagnostic considerations and how would you proceed?

7) A 48-year-old woman had a CT of the chest during evaluation for pneumonia. The radiologist made a comment about the irregular appearance of the right lobe of the thyroid gland. The patient has noticed some difficulty swallowing and a sense of pressure when she bends her neck over the past year. She cannot detect any neck abnormalities on self-examination, and physical examination by her internist also shows no palpable thyroid irregularities. The patient is sent for evaluation. How would you proceed?

8) A 21-year-old male college student presents with a right neck mass of 1 month’s duration. He reports that the mass is stable in size and nontender. He reports fatigue but no fevers, chills, or night sweats. Physical examination reveals an isolated level 2 lymph node, firm, nontender, and mobile, measuring about 1.5 cm. What are the likely diagnoses? What tests would you perform?

9) A 50-year-old male presents with progressive swelling in his calf over the past year. Physical examination reveals a significant size discrepancy between right and left lower legs, and a fullness in the calf muscles. The patient denies pain, hx of trauma, heart disease, vascular disease, or prior malignancy. How would you evaluate this problem?



Discussion by Ari D. Brooks, MD, Associate Professor of Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania



Answer 1


I am always suspicious of unintentional weight loss and early satiety. Add to that some classic B symptoms, including night sweats, chills, and a rash, and you are now looking at a lymphoma until proven otherwise. This patient will likely have lymphadenopathy in some accessible area such as the axilla, neck, or groin, but CT of the chest, abdomen, and pelvis will help identify the extent of disease. Many patients with lymphoma will have an enlarged spleen, but this is neither the source nor the major problem affecting this patient. A CBC and a lymph node biopsy are indicated to make the dx, and this patient will move on to chemotherapy with or without radiation.


At times I will be contacted later in the course of therapy to perform a splenectomy for control of pain or to improve nutritional status. In patients who are going on to bone marrow transplantation, a splenectomy may help prevent thrombocytopenia and remove residual disease.



Answer 2


This patient is high risk for cancer by family hx alone. Now, with a nontender and suspicious mass found on routine physical examination, it looks like we have found a cancer. I try to have mammography and ultrasonography done before my first office visit. Anxiety runs high in this disease, and tends to have an inverse relationship to age. My intention is to make a dx as rapidly as possible. After a careful hx and complete physical examination with attention to risks for bleeding, I perform an ultrasound-guided biopsy on the first visit. The patient’s experience with breast cancer is quite bad, with a 100% mortality rate in her family. My intention is to establish that this is truly early-stage disease, and that we caught it in time. With a positive biopsy result, I will schedule surgery (usually lumpectomy and sentinel node) quickly, and order an extent of disease workup. In the majority of cases, even with a palpable breast mass, the patient is still in stage I or II, and our discussion will focus on the excellent survival in these groups with adequate multidisciplinary management. Sometimes a mastectomy is required, if the tumor is very large, multicentric, or associated with diffuse ductal carcinoma in situ. Sometimes, a mastectomy is a good option, not for cure of this cancer, but for prevention of a recurrence, cosmetic reasons, or because the patient doesn’t want radiation. This decision doesn’t have to be made immediately, and often is done after the patient has met with my colleagues in radiation oncology, medical oncology, and plastic surgery.


After the breast surgery is complete, this young woman will likely move on to chemotherapy (all premenopausal women with a tumor >1 cm are so treated). Once that is complete, radiation therapy usually begins. When all is done, it is about 8 or 9 months since first dx. I try to prepare the woman and her family for all these steps during our first few meetings, but I keep involved during this entire year to add perspective and assist decision making. Specifically, I will help counsel the patient regarding her need for genetic testing, and if positive, I will discuss the pros and cons of prophylactic mastectomy and, more importantly, the life-saving virtues of prophylactic oophorectomy.

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  3. Splenomegaly in a 40-Year-Old Female (Case 19)
  4. The Resident as Teacher: Facilitating Student Success

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Professor’s Pearls: Surgical Oncology

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