Surgey: Breast and endocrine surgery

🩺 Breast and endocrine surgery. Most breast lumps are benign, but every new lump needs triple assessment -clinical examination, imaging and biopsy. Endocrine surgery covers the thyroid, parathyroid and adrenal glands; the key surgical risks are the recurrent laryngeal nerve, low calcium and, for adrenal tumours, unprepared phaeochromocytoma. Oncology of breast cancer is in the Breast and Gynaecological Cancers chapter; thyroid and adrenal medicine are in the Endocrinology chapters.
Your four questions for every patient: Could this be cancer -and has triple assessment (or the right tests) been done? Is the gland over- or under-working, and does that need treating before surgery? What operation is right, and what structures are at risk? What follow-up, replacement therapy or family screening is needed afterwards?

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Breast Assessment and Triple Assessment

• History -duration, change with the menstrual cycle, pain, nipple discharge, skin changes, previous breast problems, family history, HRT and contraception, pregnancy or breastfeeding.
• Examination (with a chaperone) -inspect sitting with arms by the sides, raised, and hands pressed on hips (dimpling, asymmetry, nipple changes, peau d'orange); palpate both breasts, the axillae and the supraclavicular fossae.
• Features of concern -hard, irregular, fixed lump; skin tethering or dimpling; nipple retraction (new); peau d'orange (orange-peel skin -blocked lymphatics); bloody nipple discharge; axillary nodes.
• Triple assessment (in a one-stop breast clinic):
  • Clinical examination.
  • Imaging -ultrasound under about 40 (dense breasts); mammography plus ultrasound at 40 and over; MRI in selected cases (lobular cancer, implants, high-risk, occult primary).
  • Biopsy -core needle biopsy (gives histology and receptor status) is standard; fine-needle aspiration for cysts and lymph nodes.
• Scoring -each part graded 1 (normal) to 5 (malignant); results are reviewed together at the MDT -any suspicious part needs further action, even if the others are reassuring.

Breast Referral Criteria

• Suspected cancer pathway referral (NICE NG12):
  • Aged 30 and over with an unexplained breast lump (with or without pain).
  • Aged 50 and over with any of these in one nipple only -discharge, retraction or other concerning changes.
• Consider suspected cancer referral -skin changes suggesting breast cancer, or aged 30 and over with an unexplained lump in the axilla.
• Consider non-urgent referral -under 30 with an unexplained breast lump.
• Men -a hard, painless, irregular lump (often behind the nipple) needs referral; male breast cancer is rare but real (BRCA2, Klinefelter syndrome).
• In practice -many breast units see all new lumps urgently; don't wait for the next period if a lump is clearly suspicious.

Benign Breast Lumps

Condition	Typical features	Management
Fibroadenoma	Women aged 15–35; smooth, firm, rubbery, very mobile ("breast mouse"), painless	Confirm by triple assessment; usually leave alone; excise if large (over about 3–4 cm), growing or patient wishes
Breast cyst	Women aged 35–55 (perimenopausal); smooth, well defined, may be tender; can appear quickly	Ultrasound; aspirate if symptomatic -further assessment if bloody fluid, a lump remains, or it keeps refilling
Fibrocystic change (fibroadenosis)	Lumpy, tender breasts, worse before periods	Reassure, supportive bra, analgesia; assess any distinct lump
Phyllodes tumour	Older women (40s); rapidly growing large lump; benign, borderline or malignant	Wide local excision with clear margins (recurs if incomplete)
Fat necrosis	After trauma, surgery or radiotherapy; hard, irregular, may tether skin -mimics cancer	Triple assessment to exclude cancer; resolves
Intraductal papilloma	Single duct nipple discharge (clear or bloody), small lump behind the nipple	Imaging and biopsy; excision (microdochectomy)
Lipoma	Soft, mobile, painless	Imaging if uncertain; leave or excise
Galactocele	Milk-filled cyst in a breastfeeding woman	Ultrasound; aspiration

• Atypical ductal hyperplasia and lobular carcinoma in situ (LCIS) -not cancer, but markers of higher future risk; excision or surveillance per MDT.

Breast Infection and Inflammation

• Lactational mastitis -painful, red, hot, swollen area of the breast while breastfeeding (usually milk stasis ± Staphylococcus aureus):
  • Keep breastfeeding or expressing from the affected side (safe for the baby and helps clear it), analgesia, warm compresses.
  • Antibiotics (flucloxacillin; erythromycin or clarithromycin if allergic) if not improving within 12–24 hours, systemically unwell, a nipple fissure is infected, or milk culture is positive.
• Breast abscess -a tender fluctuant lump, fever, not settling with antibiotics:
  • Ultrasound-guided needle aspiration (often repeated) with antibiotics; incision and drainage if large or not responding.
  • Non-lactational abscesses (often near the areola) -linked with smoking and periductal mastitis; mixed organisms (add metronidazole); may recur or form a mammary duct fistula.
• Periductal mastitis -young women who smoke; pain behind the nipple, nipple retraction, discharge, abscesses; stop smoking.
• Duct ectasia -older (perimenopausal) women; dilated ducts with thick green, cream or brown discharge, slit-like nipple retraction.
• Inflammatory breast cancer -a red, swollen, warm breast with peau d'orange, often without a lump, not responding to antibiotics -urgent triple assessment.
• Idiopathic granulomatous mastitis -rare, mimics abscess or cancer; biopsy; steroids or methotrexate.

Nipple Discharge and Nipple Changes

• Physiological discharge -usually from both breasts and multiple ducts, only on squeezing, clear or milky.
• Concerning discharge -single duct, spontaneous, bloody or clear (watery), one breast, a lump, age over 50.
• Causes:
  • Intraductal papilloma -commonest cause of bloody discharge.
  • Duct ectasia -thick, coloured, multiple ducts.
  • Ductal carcinoma in situ (DCIS) or cancer.
  • Galactorrhoea (milky, both sides) -pregnancy, prolactinoma, drugs (antipsychotics, metoclopramide, domperidone), hypothyroidism -check prolactin and TFTs (see the Pituitary chapter).
• Investigation -triple assessment, mammography and ultrasound; cytology of discharge has limited value; microdochectomy (single duct) or total duct excision if persistent.
• Nipple changes:
  • New nipple retraction -may be cancer (central, fixed) or duct ectasia (slit-like).
  • Paget's disease of the nipple -red, scaly, eczema-like rash starting on the nipple (eczema usually starts on the areola and spares the nipple), not responding to steroids -often with underlying DCIS or cancer -punch biopsy and triple assessment.

Breast Pain and Gynaecomastia

• Breast pain (mastalgia) -rarely a sign of cancer on its own:
  • Cyclical -both breasts, upper outer areas, worse before periods; reassurance, well-fitting bra, simple analgesia, topical NSAIDs.
  • Non-cyclical -consider chest wall pain (costochondritis), drugs (HRT, SSRIs), infection, cysts.
  • Pain alone without other symptoms usually doesn't need urgent referral -examine, and refer if a lump or worrying change is found.
• Gynaecomastia -enlarged male breast tissue (firm, rubbery disc behind the nipple, often both sides, may be tender):
  • Physiological -newborns, puberty (usually settles within 2 years), older men.
  • Drugs -spironolactone, anti-androgens (bicalutamide), GnRH analogues, oestrogens, digoxin, cimetidine, anabolic steroids, cannabis, alcohol.
  • Diseases -liver cirrhosis, kidney failure, hyperthyroidism, hypogonadism (including Klinefelter syndrome), testicular tumours (hCG or oestrogen secreting -examine the testes), adrenal tumours, lung cancer (hCG).
  • Pseudogynaecomastia -fat only (obesity), soft with no disc.
  • Tests if not clearly physiological or drug-related -LFTs, U&E, TFTs, testosterone, LH, FSH, oestradiol, prolactin, hCG and AFP; testicular ultrasound if hCG raised or a testicular lump.
  • Treat the cause; tamoxifen for painful or persistent cases (off-label, specialist); surgery for long-standing cases.
  • Hard, irregular, one-sided, eccentric lump in a man -triple assessment for cancer.

Breast Cancer Surgery

• Types -invasive ductal carcinoma (no special type -about 75%), invasive lobular carcinoma (may be multifocal or bilateral; harder to see on mammography), others; DCIS (pre-invasive, often found as microcalcifications on screening).
• Receptor status guides treatment -oestrogen receptor (ER), progesterone receptor, HER2; triple-negative cancers are more aggressive (associated with BRCA1).
• Staging -clinical examination, imaging of the breast and axilla; CT or bone scan for larger or node-positive cancers, or symptoms of spread.
• Breast-conserving surgery (wide local excision or lumpectomy) plus radiotherapy -survival equal to mastectomy for suitable tumours; wire- or marker-guided for impalpable lesions; re-excision if margins are involved.
• Mastectomy -large tumour relative to breast size, multifocal or multicentric disease, previous radiotherapy, unable to have radiotherapy, high genetic risk, or patient choice; ± reconstruction.
• Neoadjuvant (pre-operative) systemic therapy -chemotherapy (± HER2 therapy) for HER2-positive, triple-negative or large tumours, to shrink the tumour and allow breast conservation; endocrine therapy in some older women with ER-positive tumours.
• After surgery (adjuvant) -radiotherapy, endocrine therapy (tamoxifen before menopause; aromatase inhibitors after), HER2 therapy (trastuzumab), chemotherapy -tailored by risk (gene expression tests such as Oncotype DX).
• Complications of surgery -seroma, haematoma, wound infection, poor cosmesis, chronic pain, lymphoedema (axillary surgery and radiotherapy), shoulder stiffness, body image concerns.
• Older or frail women with ER-positive cancer -primary endocrine therapy may be used instead of surgery.

The Axilla and Reconstruction

• Axillary staging is essential -nodal status is a key prognostic factor.
• Before surgery -axillary ultrasound ± needle biopsy of abnormal nodes.
• Sentinel lymph node biopsy -for a clinically and ultrasound-normal axilla:
  • Radioisotope and/or blue dye (or magnetic tracer) injected near the tumour; the first draining node(s) are removed and examined.
  • Much less morbidity than clearance (lymphoedema about 5% versus up to about 25%).
  • Blue dye can cause anaphylaxis (rare) and temporarily blue urine and skin.
• Axillary node clearance (levels I–III) -for proven node-positive disease (selected cases); risks -lymphoedema, seroma, numbness of the inner upper arm (intercostobrachial nerve), winged scapula (long thoracic nerve), damage to the thoracodorsal nerve; increasingly replaced by axillary radiotherapy in some patients.
• Lymphoedema -arm swelling, heaviness; compression garments, skin care (infections -cellulitis -need prompt antibiotics), exercise, specialist lymphoedema services.
• Breast reconstruction -offered to all women having mastectomy, either at the same time (immediate) or later (delayed):
  • Implants (± tissue expanders, mesh or acellular dermal matrix) -capsular contracture, infection, rupture; BIA-ALCL (rare lymphoma linked with textured implants -late seroma around an implant).
  • Own tissue (autologous) flaps -DIEP flap (lower abdominal skin and fat), latissimus dorsi flap; longer surgery, more natural result.
  • Therapeutic mammoplasty and symmetrising surgery on the other breast; nipple reconstruction and tattooing.

Breast Screening and Family History

• NHS Breast Screening Programme -mammography every 3 years for women aged 50 to 71 (invited from 50; can self-refer after 71); trans and non-binary people may be eligible depending on registration and hormones.
• Benefits and harms -reduces breast cancer deaths; risks include overdiagnosis, false positives and anxiety -informed choice.
• Family history (NICE CG164) -assess in primary care; refer to secondary care or genetics if risk is raised (e.g. a first-degree relative diagnosed under 40, male breast cancer, bilateral breast cancer, breast and ovarian cancer in the family, Jewish ancestry with relevant history).
• High-risk genes -BRCA1 (breast, ovarian; often triple-negative), BRCA2 (breast including male, ovarian, prostate, pancreas), TP53 (Li–Fraumeni -avoid radiotherapy where possible), PALB2, CHEK2, PTEN (Cowden).
• Options for high-risk women -earlier and more frequent screening (annual MRI from 30 for BRCA carriers, with mammography from 40), chemoprevention (tamoxifen or raloxifene before menopause/after; anastrozole after menopause), risk-reducing mastectomy (reduces risk by about 90% or more) and risk-reducing salpingo-oophorectomy.
• Previous chest radiotherapy (e.g. Hodgkin lymphoma at a young age) -increased risk; earlier surveillance.

Thyroid Nodules and Neck Lumps

• Thyroid nodules are common (found on many ultrasound scans); most are benign; cancer risk is higher in children, men, the very young or old, previous neck radiation, and with family history.
• A thyroid lump moves up on swallowing; a thyroglossal cyst moves up on swallowing and on sticking out the tongue (midline).
• Assessment:
  • TFTs -a low TSH suggests a "hot" (toxic) nodule -radioisotope scan; toxic nodules are rarely cancerous.
  • Ultrasound -graded by suspicion (UK "U" scoring U1–U5): suspicious features -solid and hypoechoic, irregular margins, microcalcification, taller than wide, increased internal blood flow, abnormal nodes.
  • Fine-needle aspiration cytology (ultrasound-guided) for U3–U5 nodules -reported as Thy1–Thy5 (Thy1 non-diagnostic, Thy2 benign, Thy3 uncertain -Thy3a/Thy3f, Thy4 suspicious, Thy5 malignant).
  • Thy3f (follicular lesion) -cytology can't tell follicular adenoma from carcinoma -diagnostic hemithyroidectomy.
• Red flags (urgent referral, NICE NG12 -unexplained thyroid lump; urgent same-day/very fast assessment if stridor) -rapidly growing lump, hoarse voice (recurrent laryngeal nerve), stridor, hard or fixed lump, neck nodes, a lump in a child.
• Goitre (enlarged thyroid) -surgery if compressing (breathing or swallowing difficulty, retrosternal extension), cancer suspected, toxic and not suitable for other treatment, or cosmetic concern.
• Other neck lumps (branchial cysts, lymph nodes, salivary gland lumps) -see the Head and Neck Lumps and Cancer chapter.

Thyroid Cancer

Type	Key features	Treatment and markers
Papillary (about 80%)	Young adults, women; spreads to lymph nodes; radiation exposure; excellent prognosis; "Orphan Annie" nuclei, psammoma bodies	Hemithyroidectomy (small, low-risk) or total thyroidectomy ± neck dissection; radioiodine for higher risk; thyroglobulin to monitor
Follicular (about 10%)	Middle-aged; spreads by blood (lung, bone); iodine deficiency; diagnosis needs histology (capsular or vascular invasion)	Total thyroidectomy (for invasive tumours), radioiodine; thyroglobulin
Medullary (about 5%)	From parafollicular C cells; secretes calcitonin (and CEA); about 25% inherited -MEN2 (RET gene)	Total thyroidectomy and central neck dissection; exclude phaeochromocytoma first; RET testing and family screening; radioiodine doesn't work
Anaplastic (rare)	Older people; rapidly growing hard mass; compresses airway; very poor prognosis	Palliative care, radiotherapy, airway protection; targeted therapy if BRAF mutation
Lymphoma	Rapid growth in a woman with Hashimoto's thyroiditis	Chemotherapy ± radiotherapy

• After surgery for differentiated cancer -levothyroxine (dose to suppress TSH in higher-risk patients), radioactive iodine ablation (avoid pregnancy for at least 6 months; isolate for a few days), follow-up with thyroglobulin (and thyroglobulin antibodies) and ultrasound.
• Very small low-risk papillary cancers -active surveillance is an option in some.

Thyroidectomy and Its Complications

• Operations -hemithyroidectomy (lobectomy -one side; may not need levothyroxine) or total thyroidectomy (lifelong levothyroxine).
• Indications -cancer or indeterminate nodule, compressive or retrosternal goitre, Graves' disease (relapse, large goitre, eye disease, pregnancy plans, patient choice), toxic multinodular goitre or toxic adenoma.
• Before surgery:
  • Make the patient euthyroid (carbimazole or propylthiouracil); Lugol's iodine for 10 days before surgery in Graves' disease reduces blood flow; beta-blockers for symptoms.
  • Vocal cord check (laryngoscopy) before surgery -documents baseline function, especially after previous neck surgery or with a hoarse voice.
  • Calcium and vitamin D -correct low vitamin D before surgery (reduces post-op low calcium).
  • Exclude phaeochromocytoma before medullary cancer surgery.
• Complications:
  • Neck haematoma -a surgical emergency within the first 24 hours -swelling, difficulty breathing, stridor → open the wound at the bedside ("SCOOP" -skin exposure, cut sutures, open skin, open muscles, pack) and call for senior help; a stitch cutter is kept at the bedside.
  • Recurrent laryngeal nerve injury -hoarse voice (one side), weak cough, aspiration; both sides -stridor and airway obstruction after extubation (may need reintubation or tracheostomy); nerve monitoring is often used during surgery.
  • External branch of the superior laryngeal nerve -loss of high pitch and voice fatigue (important for singers).
  • Hypocalcaemia -from parathyroid damage or removal (usually after total thyroidectomy); tingling around the mouth and fingers, muscle cramps, Chvostek's sign (facial twitch on tapping) and Trousseau's sign (carpal spasm with a BP cuff), prolonged QT, seizures; check calcium or PTH after surgery; oral calcium ± alfacalcidol; IV calcium gluconate if severe or symptomatic.
  • Hypothyroidism (all after total thyroidectomy; some after hemithyroidectomy).
  • Thyroid storm -if surgery is done on a hyperthyroid patient (rare now -prevent by preparation).
  • Wound infection, keloid scar, tracheomalacia (after long-standing large goitres -rare).

Parathyroid Surgery

• Primary hyperparathyroidism -high calcium with an inappropriately normal or high PTH:
  • Usually a single parathyroid adenoma (about 85%); hyperplasia of all four glands (MEN1, MEN2A, familial); carcinoma (rare -very high calcium, neck mass).
  • Symptoms -"bones, stones, abdominal groans and psychic moans" (bone pain, osteoporosis, kidney stones, abdominal pain, constipation, pancreatitis, peptic ulcers, low mood, confusion), thirst and polyuria; many are found on routine bloods.
  • Exclude familial hypocalciuric hypercalcaemia -low urinary calcium (calcium/creatinine clearance ratio under about 0.01) -surgery doesn't help.
• Indications for surgery (NICE NG132) -symptoms, end-organ disease (kidney stones, osteoporosis or fragility fracture, reduced kidney function), calcium 2.85 mmol/L or more, younger age; surgery is the only cure and is usually offered to most fit patients.
• Localisation before surgery -ultrasound and sestamibi scan (or 4D-CT, choline PET) → focused (minimally invasive) parathyroidectomy if one gland is found; otherwise bilateral neck exploration.
• After surgery:
  • Hungry bone syndrome -severe, prolonged low calcium, phosphate and magnesium as bones take up calcium (especially with severe bone disease) -IV and oral calcium, alfacalcidol, magnesium.
  • Recurrent laryngeal nerve injury, haematoma (rare).
  • Persistent or recurrent disease -missed or extra glands.
• Not fit or declines surgery -cinacalcet (lowers calcium), bisphosphonates for bone, fluids, avoid thiazides and dehydration.
• Secondary and tertiary hyperparathyroidism (CKD) -see the Renal chapters; parathyroidectomy if refractory.

Adrenal Surgery

• Adrenal incidentaloma -a lump found by chance on a scan (common):
  • Two questions -is it secreting hormones? and could it be cancer?
  • Hormone tests for all -overnight dexamethasone suppression test (cortisol), plasma or urine metanephrines (phaeochromocytoma); aldosterone/renin ratio if hypertensive or low potassium; sex hormones if virilisation.
  • Imaging -a small (under 4 cm), homogeneous, low-density (under 10 Hounsfield units) lesion on CT is a benign adenoma; large, irregular or high-density lesions need further imaging or surgery.
• Indications for adrenalectomy -phaeochromocytoma, Conn's adenoma (one-sided aldosterone excess confirmed by adrenal vein sampling), Cushing's from an adrenal adenoma, suspected adrenocortical carcinoma (large, irregular, rapid growth -open surgery), large (over about 4–6 cm) or growing lesions.
• Approach -laparoscopic adrenalectomy (transabdominal or retroperitoneal) for most.
• Phaeochromocytoma -preparation is essential:
  • Alpha-blockade first (phenoxybenzamine or doxazosin) for 10–14 days; then beta-blocker only after alpha-blockade (beta-blocker first → unopposed alpha → hypertensive crisis).
  • High-salt diet and fluids (expand blood volume -reduces post-op low BP); careful anaesthesia (BP swings on handling the tumour).
  • After removal -low blood pressure and low blood glucose; genetic testing (about 30–40% inherited -MEN2, VHL, NF1, SDH genes); lifelong follow-up with metanephrines.
• After adrenalectomy for cortisol excess -the other adrenal is suppressed → steroid cover and a slow wean (risk of adrenal crisis); steroid emergency card.
• After Conn's -stop spironolactone and potassium; risk of high potassium for a few weeks; BP often improves.

Pancreatic Neuroendocrine Tumours and MEN

• Pancreatic neuroendocrine tumours:
  • Insulinoma -fasting hypoglycaemia (Whipple's triad -symptoms of low glucose, low glucose measured, relief with glucose); high insulin and C-peptide during low glucose (exclude sulphonylurea use); usually benign; localise (CT, MRI, EUS) → enucleation or resection; diazoxide meanwhile.
  • Gastrinoma (Zollinger–Ellison) -multiple or unusual peptic ulcers, diarrhoea; high gastrin off PPI; often in the duodenum; MEN1 in about a quarter.
  • Others -VIPoma (watery diarrhoea, low potassium), glucagonoma (necrolytic migratory erythema, diabetes, weight loss), somatostatinoma, non-functioning tumours (most common -present with mass effect or spread).
  • Investigation -chromogranin A, specific hormones, CT/MRI, EUS, Ga-68 DOTATATE PET; treatment -surgery, somatostatin analogues, PRRT (radiolabelled therapy), targeted drugs.
• Multiple endocrine neoplasia (MEN) -autosomal dominant:

  Type	Gene	Features
  MEN1	MEN1 (menin)	"3 Ps" -parathyroid hyperplasia (most common, high calcium), pituitary tumours (prolactinoma), pancreatic NETs (gastrinoma, insulinoma)
  MEN2A	RET	Medullary thyroid cancer, phaeochromocytoma, parathyroid hyperplasia
  MEN2B	RET	Medullary thyroid cancer (early, aggressive), phaeochromocytoma, marfanoid habitus, mucosal neuromas (lips and tongue)

• RET carriers -prophylactic thyroidectomy in childhood (age depends on the specific mutation -in the first year of life for MEN2B).
• Other syndromes -von Hippel–Lindau (phaeochromocytoma, pancreatic NETs, renal cancer, haemangioblastomas), NF1, paraganglioma syndromes (SDH genes).

Breast and Endocrine Conditions at a Glance

Condition	Key clues	Management
Breast cancer	Hard, irregular, fixed lump; dimpling; nipple retraction	Triple assessment, surgery, axillary staging, adjuvant therapy
Fibroadenoma	Young woman, smooth, very mobile	Triple assessment; usually leave
Breast cyst	Perimenopausal, smooth, may appear suddenly	Ultrasound, aspirate
Lactational mastitis	Red tender breast while breastfeeding	Keep feeding; flucloxacillin if not settling
Breast abscess	Fluctuant tender lump, fever	Ultrasound-guided aspiration, antibiotics
Paget's of the nipple	Eczema starting on the nipple	Punch biopsy, triple assessment
Intraductal papilloma	Bloody single-duct discharge	Imaging, microdochectomy
Gynaecomastia	Rubbery disc behind the nipple in a man	Review drugs, liver, testes, hCG
Papillary thyroid cancer	Young woman, nodule, neck nodes	Thyroidectomy ± radioiodine; thyroglobulin
Medullary thyroid cancer	Raised calcitonin, MEN2	Exclude phaeo; total thyroidectomy; RET test
Post-thyroidectomy haematoma	Neck swelling and stridor in first 24 hours	Open wound at bedside, senior help
Post-thyroidectomy hypocalcaemia	Perioral tingling, Chvostek's, Trousseau's	Calcium (IV if severe) ± alfacalcidol
Primary hyperparathyroidism	High calcium with normal or high PTH	Localise (US, sestamibi), parathyroidectomy
Phaeochromocytoma	Episodic headache, sweating, palpitations; high metanephrines	Alpha-block then beta-block, adrenalectomy
Insulinoma	Fasting hypoglycaemia, high insulin and C-peptide	Localise and resect

Spot the Diagnosis

Clue	Diagnosis
Smooth, rubbery, very mobile 2 cm lump in a 22-year-old	Fibroadenoma
Sudden smooth tender lump in a 48-year-old; aspirates green fluid and disappears	Breast cyst
Rapidly enlarging large breast lump in a 45-year-old	Phyllodes tumour
Hard irregular lump at the site of a seatbelt bruise	Fat necrosis (still needs triple assessment)
Red, swollen breast with peau d'orange not responding to antibiotics	Inflammatory breast cancer
Recurrent periareolar abscesses in a 30-year-old smoker	Periductal mastitis
Thick green discharge from several ducts with slit-like nipple retraction	Duct ectasia
Scaly red rash on one nipple that started on the nipple itself	Paget's disease of the nipple
Bilateral milky discharge in a woman on risperidone	Drug-induced hyperprolactinaemia
Microcalcifications on a screening mammogram with no lump	DCIS
Arm swelling 2 years after axillary clearance	Lymphoedema
Winged scapula after axillary surgery	Long thoracic nerve injury
Late swelling around a textured breast implant	Consider BIA-ALCL
Bilateral breast enlargement in a man on spironolactone	Drug-induced gynaecomastia
Gynaecomastia with a raised hCG in a 28-year-old	Testicular germ cell tumour
Midline neck lump that moves up on tongue protrusion	Thyroglossal cyst
Thyroid nodule with Thy3f cytology	Follicular lesion -diagnostic hemithyroidectomy
Thyroid nodule with very high calcitonin	Medullary thyroid cancer
Rapidly enlarging thyroid in a woman with Hashimoto's	Thyroid lymphoma
Stridor and neck swelling 4 hours after thyroidectomy	Neck haematoma -open the wound
Hoarse voice after thyroidectomy	Recurrent laryngeal nerve injury
Perioral tingling and carpal spasm on day 1 after total thyroidectomy	Hypocalcaemia (hypoparathyroidism)
High calcium, high PTH and low urinary calcium	Familial hypocalciuric hypercalcaemia -no surgery
Very low calcium and phosphate after parathyroidectomy for severe bone disease	Hungry bone syndrome
Hypertension, low potassium and a one-sided adrenal adenoma on venous sampling	Conn's adenoma -adrenalectomy
Hypertensive crisis after starting propranolol for a phaeochromocytoma	Unopposed alpha stimulation
Medullary thyroid cancer, phaeochromocytoma and mucosal neuromas with a marfanoid build	MEN2B
Hypercalcaemia, prolactinoma and recurrent peptic ulcers	MEN1

Exam-style Scenarios

1. A 56-year-old woman has a 2 cm hard, irregular lump in the upper outer left breast with skin dimpling. Mammography and ultrasound show a suspicious mass; core biopsy shows invasive ductal carcinoma, ER-positive, HER2-negative. Axillary ultrasound is normal.
Answer: Early breast cancer suitable for breast-conserving surgery.

• MDT discussion; wide local excision with sentinel lymph node biopsy, followed by radiotherapy.
• Adjuvant endocrine therapy (an aromatase inhibitor -postmenopausal) for at least 5 years; chemotherapy decided by risk (gene expression testing); bone health check with aromatase inhibitors.
• Breast care nurse support; lymphoedema advice; follow-up mammography.

2. A 29-year-old woman is breastfeeding her 3-week-old baby. She has a 2-day painful red wedge-shaped area on the right breast, temperature 38.2°C, and feels unwell. No fluctuant lump.
Answer: Lactational mastitis.

• Continue breastfeeding or expressing from both breasts; analgesia (paracetamol or ibuprofen), warm compresses, fluids.
• Systemically unwell → oral flucloxacillin for 10–14 days (erythromycin or clarithromycin if penicillin-allergic); send milk for culture if recurrent or not responding.
• Ultrasound if a lump develops or no improvement in 48 hours (abscess -aspiration); refer urgently if very unwell or sepsis.

3. A 47-year-old woman has a total thyroidectomy for Graves' disease. Three hours later she is anxious and short of breath with a swollen, tense neck and noisy breathing. SpO₂ is 92%.
Answer: Post-thyroidectomy haematoma with airway compromise.

• Call for senior surgical and anaesthetic help; high-flow oxygen; sit up.
• Open the wound at the bedside -cut skin sutures and the deeper muscle layer to release the clot (SCOOP).
• Return to theatre to stop bleeding; prepare for a difficult airway (intubation may be needed).

4. A 60-year-old woman has a calcium of 2.92 mmol/L, PTH 12 pmol/L (raised), eGFR 55, and a recent kidney stone. Urinary calcium is high. Ultrasound and sestamibi show a right inferior parathyroid adenoma.
Answer: Primary hyperparathyroidism with an indication for surgery.

• Familial hypocalciuric hypercalcaemia is unlikely (high urinary calcium).
• Offer focused parathyroidectomy (calcium over 2.85, kidney stones, reduced kidney function); DEXA scan; fluids; avoid thiazides.
• After surgery -check calcium and PTH; watch for hungry bone syndrome; cinacalcet if surgery is not possible.

5. A 42-year-old man has episodic headaches, sweating and palpitations with BP 190/110 during attacks. Plasma metanephrines are very high. CT shows a 4 cm right adrenal mass.
Answer: Phaeochromocytoma.

• Alpha-blockade first (phenoxybenzamine or doxazosin) for 10–14 days with liberal salt and fluids; add a beta-blocker only after alpha-blockade if tachycardic.
• Laparoscopic adrenalectomy with experienced anaesthesia (BP swings); after surgery watch for low BP and low glucose.
• Genetic testing (MEN2, VHL, SDH, NF1) and lifelong metanephrine follow-up; screen relatives if a mutation is found.

Key Points

• Every new breast lump needs triple assessment -examination, imaging (ultrasound under 40, mammography plus ultrasound 40 and over) and core biopsy.
• Refer on the suspected cancer pathway if aged 30 or more with an unexplained breast lump, or 50 or more with one-sided nipple changes.
• Fibroadenomas -young, mobile; cysts -perimenopausal, aspirate.
• Mastitis -keep breastfeeding; flucloxacillin if not settling; abscesses -ultrasound-guided aspiration.
• Red breast not responding to antibiotics -think inflammatory breast cancer.
• Paget's of the nipple starts on the nipple; eczema starts on the areola.
• Bloody single-duct discharge -intraductal papilloma most often, but exclude cancer.
• Gynaecomastia -check drugs, liver, kidneys, thyroid, testes and hCG.
• Sentinel node biopsy for a clinically normal axilla; clearance risks lymphoedema and nerve injury.
• BRCA carriers -annual MRI, chemoprevention, risk-reducing surgery.
• Thyroid nodules -TFTs, ultrasound (U score), FNA (Thy score); Thy3f needs hemithyroidectomy.
• Papillary spreads to nodes; follicular by blood; medullary secretes calcitonin and is linked with MEN2.
• Exclude phaeochromocytoma before surgery for medullary thyroid cancer.
• Post-thyroidectomy haematoma with stridor -open the wound at the bedside.
• Recurrent laryngeal nerve injury -hoarseness; bilateral -stridor.
• Post-thyroidectomy low calcium -perioral tingling, Chvostek's and Trousseau's signs; IV calcium gluconate if severe.
• Primary hyperparathyroidism -localise with ultrasound and sestamibi; exclude FHH with urinary calcium.
• Phaeochromocytoma -alpha-block before beta-block; genetic testing.
• MEN1 -parathyroid, pituitary, pancreas; MEN2 -medullary thyroid cancer and phaeochromocytoma.

Guidelines and Further Reading

• NICE NG12: Suspected cancer -recognition and referral
• NICE NG101: Early and locally advanced breast cancer
• NICE CG164: Familial breast cancer
• Association of Breast Surgery: Best practice guidelines for surgeons in breast cancer screening and symptomatic breast referrals
• NICE CKS: Mastitis and breast abscess; Gynaecomastia; Breast pain
• NICE NG145: Thyroid disease -assessment and management
• British Thyroid Association: Guidelines for the management of thyroid cancer
• NICE NG230: Thyroid cancer -assessment and management
• NICE NG132: Hyperparathyroidism (primary)
• European Society of Endocrinology: Management of adrenal incidentalomas
• Endocrine Society: Pheochromocytoma and paraganglioma guidelines
• Difficult Airway Society: Management of haematoma after thyroid surgery
• BNF -for current doses