A breast cyst is a fluid-filled sac within the breast. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but can also feel firm.

Breast cysts can be painful and may be worrisome but are generally benign. They are most common in pre-menopausal women in their 30s or 40s. They usually disappear after menopause, but may persist or reappear when using hormone therapy. They are also common in adolescents. Breast cysts can be part of fibrocystic disease. The pain and swelling is usually worse in the second half of the menstrual cycle or during pregnancy.

The halo sign, described as a complete or partial radiolucent ring surrounding the periphery of a breast mass, has long been considered a mammographic sign indicating a benign process. The phenomenon is most frequently seen with cysts and fibroadenomas.

Adrenal adenomas are benign tumours of the adrenal glands, which can be either functioning or non-functioning. Though the majority are clinically silent, functional adenomas from the cortex of medulla can lead to overproduction of any of their associated hormones. Benign adenomas often have a lipid rich core that is readily identifiable on CT scanning. In addition the nodules are often well circumscribed.

Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered.

Sentinel lymph node biopsy has become the gold standard for axillary staging for patients with clinically and radiologically node negative axilla. The recommended technique is the dual technique of blue dye/radioisotope and this is associated with high sentinel node identification rates (> 95 %). However, in centres where radioisotope is not available, blue dye guided four node sampling appears to be a reasonable alternative. Sentinel node biopsy was shown to be an accurate technique for axillary node staging in the ALMANAC Trial with less associated morbidity and strong health economic arguments for its use.

The tumour in this patient is small so a wide local excision should be done.
Lumpectomy or breast wide local excision is a surgical removal of a discrete portion or lump of breast tissue, usually in the treatment of a malignant tumour or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumours.

Hypertension in a young patient without any obvious cause should be investigated.

A pheochromocytoma is a catecholamine-secreting tumour typically located in the adrenal medulla. Pheochromocytomas are usually benign (∼ 90% of cases) but may also be malignant. Classic clinical features are due to excess sympathetic nervous system stimulation and involve episodic blood pressure crises with paroxysmal headaches, diaphoresis, heart palpitations, and pallor. However, a pheochromocytoma may also present asymptomatically or with persistent hypertension. Elevated catecholamine metabolites in the plasma or urine confirm the diagnosis, while imaging studies in patients with positive biochemistry are used to determine the location of the tumour. Surgical resection is the treatment of choice, but is only carried out once alpha blockade with phenoxybenzamine has become effective.

Pheochromocytoma is said to follow a 10% rule:

,10% are extra-adrenal
,10% are bilateral
,10% are malignant
,10% are found in children
,10% are familial
,10% are not associated with hypertension
,10% contain calcification

Answer: Waterhouse- Friderichsen syndrome

Waterhouse-Friderichsen syndrome is a condition characterized by the abrupt onset of fever, petechiae, arthralgia, weakness, and myalgias, followed by acute haemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction. The syndrome is most often associated with meningococcal septicaemia but may occur as a complication of sepsis caused by other organisms, including certain streptococcal species. This disorder may be associated with a history of splenectomy.

Fulminant infection from meningococcal bacteria in the bloodstream is a medical emergency and requires emergent treatment with vasopressors, fluid resuscitation, and appropriate antibiotics. Benzylpenicillin was once the drug of choice with chloramphenicol as a good alternative in allergic patients. Ceftriaxone is an antibiotic commonly employed today. Hydrocortisone can sometimes reverse the adrenal insufficiency. Amputations, reconstructive surgery, and tissue grafting are sometimes needed as a result of tissue necrosis (typically of the extremities) caused by the infection.

Carbimazole was not found to cause gynaecomastia.

Drugs frequently causing gynecomastia:
Antiandrogens – Bicalutamide, flutamide, finasteride, dutasteride
Antihypertensive – Spironolactone
Antiretroviral – Protease inhibitors (saquinavir, indinavir, nelfinavir, ritonavir, lopinavir), reverse transcriptase inhibitors (stavudine, zidovudine, lamivudine)
Environmental exposure – Phenothrin (antiparasitic)
Exogenous hormones – Oestrogens, prednisone (male teenagers)
Gastrointestinal drugs – H2 histamine receptor blockers (cimetidine)

Mnemonic for causes of gynaecomastia: METOCLOPRAMIDE

M etoclopramide
E ctopic oestrogen
T rauma skull/tumour breast, testes
O rchitis
C imetidine, Cushings
L iver cirrhosis
O besity
P araplegia
R A
A cromegaly
M ethyldopa
I soniazid
D igoxin
E thionamide

Duct ectasia is the cause of nipple discharge, with different percentages recorded in different articles (>10%, >30% and >50%). Duct ectasia differs from cystic disease since it is an inflammatory process, usually affecting the ducts below the nipple. It develops gradually, either through the ductal system or the breast lobes. The acute inflammation may be caused by epithelial rupture and diffusion of the contents into the fibrous duct-wall and the underlying structures. These contents consist of neutral fat and lipid crystals that are typical of duct ectasia. The chronic granulation-type reaction may develop foreign body-like giant cells and a multiform inflammatory cell population. Since the whole process in duct ectasia is long in duration, plasma cells are sometimes dominant in the inflammatory infiltrations. Other findings in duct ectasia include the following:
-Serous or green-white nipple discharge in 20% of cases;
-Nipple inversion that leads to fibrosis and development of ring or tubular calcification (this finding is typical in the mammogram and especially when the disease is in its advanced stages);
-Apocrine metaplasia with or without epithelial hyperplasia. The epithelial layer consists of widened atrophic cells.
The condition may be managed symptomatically and/or with antibiotics, but in persistent or recurrent cases it is managed with surgical excision of the ducts below the nipple. A focused excision is preferred to a complete subareolar excision since the later technique is associated with higher rates of seroma formation, nipple numbness and nipple inversion. The Hadfield’s procedure (major duct excision) is an option.

Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes.
The thyroid gland may become firm, large, and lobulated in Hashimoto’s thyroiditis, but changes in the thyroid can also be nonpalpable. Enlargement of the thyroid is due to lymphocytic infiltration and fibrosis, rather than tissue hypertrophy.

Laboratory studies and potential results for patients with suspected Hashimoto thyroiditis include the following:
– Serum thyroid-stimulating hormone (TSH) levels: Sensitive test of thyroid function; levels are invariably raised in hypothyroidism due to Hashimoto thyroiditis and in primary hypothyroidism from any cause
– Free T4 levels: Needed to correctly interpret the TSH in some clinical settings; low total T4 or free T4 level in the presence of an elevated TSH level further confirms diagnosis of primary hypothyroidism
– T3 levels: Low T3 level and high reverse T3 level may aid in the diagnosis of nonthyroidal illness

Thyroid autoantibodies: Presence of typically anti-TPO (anti-thyroid peroxidase) and anti-Tg (anti-thyroglobulin) antibodies delineates the cause of hypothyroidism as Hashimoto thyroiditis or its variant; however, 10-15% of patients with Hashimoto thyroiditis may be antibody negative.
While their role in the initial destruction of the follicles is unclear, antibodies against thyroid peroxidase (TPO) (also called TPOAb) or thyroglobulin are relevant, as they serve as markers for detecting the disease and its severity. They are hypothesized to be the secondary products of the T cell mediated destruction of the gland.

Axillary dissection is a surgical procedure that incises the axilla to identify, examine, or remove lymph nodes. Axillary dissection has been the standard technique used in the staging and treatment of the axilla in breast cancer.
Axillary dissection should be reserved for patients with proven axillary disease preoperatively or with a positive sentinel node biopsy.

Axillary dissection is only therapeutic in patients who are node positive.

Wide local excision (Lumpectomy) is defined as complete surgical resection of a primary tumour with a goal of achieving widely negative margins (ideally a 1-cm margin around the lesion). It is applicable in most patients with stage I and stage II invasive carcinomas. This patient has a tumour size of 2cm which is small hence wide local excision should be done.