Surgey: Breast and endocrine surgery

• Breast: Breast Assessment and Triple Assessment | Breast Referral Criteria | Benign Breast Lumps | Breast Infection and Inflammation | Nipple Discharge and Nipple Changes | Breast Pain and Gynaecomastia | Breast Cancer Surgery | The Axilla and Reconstruction | Breast Screening and Family History
• Endocrine: Thyroid Nodules and Neck Lumps | Thyroid Cancer | Thyroidectomy and Its Complications | Parathyroid Surgery | Adrenal Surgery | Pancreatic Neuroendocrine Tumours and MEN
• Revision: Breast and Endocrine Conditions at a Glance | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🩺 Breast and endocrine surgery — page 6 of the Surgery chapter. 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?

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

• 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

• 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

Spot the Diagnosis

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.