Answers 3/2/2012

Mystery Person: Benjamin Franklin

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. A A D D A G E E D F

Case A Lateral Mid-Neck Mass (v2) 1. What workup will you perform to locate a primary source for this lesion? Thyroid imaging with either CT scan (without contrast) or MRI is indicated (if the F.N.A. cytology is consistent with thyroid origin; most surgeons would proceed to surgery w/o additional pre-op biopsy of the thyroid). Iodinated contrast is not used because of the uptake by the thyroid and any metastatic tumor which complicates adjuvant treatment (Tx). 2. Give a realistic differential diagnosis for a solid lateral mid neck mass in the adult. A solid lateral mid-neck mass (especially without associated inflammatory focus) in the adult patient is usually malignant. Differential Dx would include: squamous cancer, (usually arising in squamous respiratory epithelium or the skin of the head/neck), adenocarcinoma (usually from a distant site but also may occur in salivary glands and skin appendages), thyroid cancer, and lymphoma. 3. How would this differential change if the patient was a child age 8? A lateral mid-neck mass in a child (solid or cystic) in most commonly benign. Differential includes: lymphoma, congenital branchial cleft anomalies/remnants, vascular and lymphatic malformations/hemangioma, and inflammatory cervical adenopathy (eg atypical T.B.) 4. A) If your workup (described in #1) confirms a primary tumor in the thyroid, what treatment would you recommend? The patient requires total thyroidectomy and modified neck dissection (bilateral if necessary) for removal of any accessible metastatic disease found in the neck. B) If the patient had (pre-op) an abnormal plain skull X-Rays which was highly suggestive of bony metastasis; how would this change your surgical treatment plan? Total thyroidectomy would be done even in the presence of known skeletal metastasis. Removal of all functioning thyroid tissue is necessary for successful (and life-prolonging). Tx of metastatic foci using I 131 Ablation.

Case B Intra-Oral Lesion (Mr. Michaels) 1) What is the next most essential diagnostic step for Mr. Michaels? a. How would you do it? Mr. Michaels has an ulcerated lesion on the posterior third of the tongue which is consistent with squamous carcinoma. The most essential diagnostic step is a biopsy. This could be incisional biopsy or punch biopsy, easily performed in the office suite under local or topical anesthetic. Excisional biopsy, needle biopsy or needle aspiration cytology are not indicated for the primary lesion in this case. Other workup would include a complete history and physical examination with a focus on the characteristics of the lesion itself, complete examination of the remaining oral cavity and regional lymph nodes in the neck. Also important would be possible sites for distant metastasis from squamous carcinoma in the upper aerodigestive tract including lung and liver. Patient would need at least indirect or endoscopic laryngoscopy which also could be an office procedure, and any other workup indicated by positive findings in the history and physical. 2) If a malignant diagnosis is established, what 2 diagnostic imaging studies would be most important? Imaging for staging of this tumor would include chest x-ray and CT scan of the neck lymph node drainage basins and primary site (with contrast). Alternatively, a CT scan of the chest could be performed and possibly a MRI of the head of neck. The latter procedure is generally less available and more expensive. CT scan is more efficient in picking up abnormality involving bone, such as the mandible adjacent to the tongue lesion, while MRI is better for visualization of soft tissue structures. The CT scan with contrast, if the patient would tolerate it, is probably the best for visualizing lymphadenopathy in the head and neck region. Case C Mr. Dunlop 1. What workup is mandatory for Mr. Dunlop? Cystoscopy (with biopsies, as indicated) Urine Cytology CT Urogram (CT with & w/o contrast of abdomen and pelvis) 2. This photo taken during Mr. Dunlops cystoscopy reveals a large papillary mass. Multiple biopsies reveal a low grade transitional cell carcinoma of the bladder which is invasive but confined to the bladder mucosa. Other workup is negative. What treatment would you recommend? Transurethral resection of all bladder tumors is essential. For some stages of invasive but superficial bladder cancer and for recurrent superficial bladder tumors, intravesical chemotherapy, is added. 3. What risk factors for bladder cancer can you list? (Generally, not specific to Mr. Dunlop) Smoking Chemical Carcinogen Exposure; (some petrochemicals and aniline dye) Pelvic Irradiation

Chronic Irritation (Bladder Stones) Some cytotoxic chemotherapy e.g. Cytoxan (urinary excretion) Schistosomiasis 4. Give a detailed follow-up plan for Mr. Dunlop for the next 2 years. (Following successful treatment for his bladder cancer) Mr. Dunlop needs surveillance cystoscopy and urine cytology for his bladder cancer 3 to 4 times each year and repeat CT urogram with contrast at least every two years. There is a significant incidence of bladder recurrence and also other primary transitional cell cancers occurring in the renal collecting system. (renal pelvis & ureter) 5. Final surgical staging for Mr. Dunlop is: T1NoMo; his expected survival rate is closest to: d. 90% Case D Mr. AA 1) What is the next management step for Mr. AA? How should it be performed? Trans-rectal ultrasound-guided prostate biopsies 2) A diagnosis of Carcinoma of the prostate (Gleason Score 5) is made. Staging workup should include: In patients with clinically localized prostate cancer; the PSA level and the Gleason score (fundamentally, the histologic grade and local extent or density of the cancer within the prostate) accurately predicts the risk of local invasion or nodal metastasis. For Mr. AA, with a PSA < 10 and a Gleason score of 5, the risk for nodal metastasis is >2%. On that basis, no further pre-treatment staging workup is absolutely required. 3) Mr. AAs staging summary is T1cN0M0 (Stage I). What treatment options can you offer? Give at least TWO. Treatment options in general include (Radical) prostatectomy or radiotherapy (by external beam or brachytherapy). Other modalities remain in clinical trials.