MC exam 1 review.docx

[Disease Prevention & Preventative Measures] - Infancy and Childhood (0-9) - Immunizations - Nutrition - Mental health services - Adolescence (10-19) - Contraception and condoms - Immunizations - Nutrition - Reproductive years (15-49) - Contr...

[Disease Prevention & Preventative Measures] - Infancy and Childhood (0-9) - Immunizations - Nutrition - Mental health services - Adolescence (10-19) - Contraception and condoms - Immunizations - Nutrition - Reproductive years (15-49) - Contraception and condoms - Pap smears - Prenatal and antenatal care - Nutrition (iron/folate) - Post reproductive (45+) - Pap smears - Mammograms - Nutrition (calcium/vitamin D) - PCP visits [Preventative Care] - HPV Vaccine - Gardasil 9 - Covers HPV 6, 11, 16, 18 (31, 33, 45, 52, and 58) - Recommended for ages 9-45 - 2 doses for under 15 (6-12 months after 1^st^ dose) - 3 doses for over 15 (0, 1-2 months, then 6 months) - Pap smear/HPV test - Screening for cervical cancer; diagnostic test for cervical pathology - USPTF/ACOG schedule - 21-29 cervical cytology only every 3 years - 30-65 cervical cytology only every 3 years, HPV testing every 5 years, or co-test every 5 years - Over 65 screening not recommended - ACS guidelines - No screening for those 21-25 - 25-65 HPV test every 5 years, co-test every 5 years, or Pap every 3 years - Mammogram - Screening for breast cancer, diagnostic test for breast pathology - USPSTF schedule - 40-49 depending on individual risks, every 2 years - 50-74, every 2 years - ACS schedule - 40 & 44 option to screen annually - 45-54 needed annually - 55+ every other year or can choose to continue annual screenings. Screening should continue as long as a woman is in good health and expected to live at least 10 more years - ACOG guidelines - Similar to ACS, but stopping at 75 years old [Interviewing/History Taking] - Get the chief complaint - HPI - Menstrual history - Age at menarche - Last menstrual period - Menstrual patterns - Cycle length, duration of flow, amount of flow, associated pain, intermenstrual bleeding - Perimenopause/Menopause - Bleeding pattern, vasomotor symptoms, hormone replacement therapy - Contraception - Current method - Previous methods, complications, reasons d/c - Cervical and vaginal cytology - Most recent pap smear results - History of abnormal pap results, diagnosis, treatment, follow-up - Infection - h/o STI - h/o vaginitis (types, frequency, treatment) - h/o PID - Fertility/Infertility - Desire for future fertility - Any difficulty conceiving in past? If so, prior evaluations and treatments - Sexual history - Number of partners - Sexual orientation - Men, women, both - Type oral, vaginal, anal - Condom use (always, sometimes, never) - h/o sexual abuse or sexual assault - Obstetric history - Describe each pregnancy and outcome - G, T-P-A-L Gravida (total number), Term births -- Preterm births -- abortions -- living children - Vaginal vs Cesarean delivery - Describe any maternal, fetal, or neonatal complications - Past medical history - Current or past illness - Hospitalization - Past surgical history - Past GYN surgeries - Past non-GYN surgeries - Medications and Allergies - Rx, OTC, and herbal preparations - Allergies to medications and nature of reactions - Family history - Significant illnesses of family members - Hereditary conditions (breast/ovarian cancers) - Social history - Marital or relationship status - Level of education - Occupation - Tobacco, ETOH, illicit drug use - Health maintenance - Diet - Calcium and folate intake - Use of seatbelts - Results of screening tests (mamos) - Immunizations (HPV, COVID, etc) - ROS - Abdomino-pelvic - GYN, urinary, GI - Breast - Other [Focused and Complete Physical exams] - Include breast, abd, and pelvic organs - 1^st^ pelvic, patient never sexually active before weigh risk vs. benefits - Optimize patient comfort - Say what is being done and when - Empty bladder - Chaperone for exams and procedures - Diagnostic Lab procedures - UA - Urine cultures - Other cultures - HSV, HPV, GC/CT - HIV, syphilis - Pregnancy test - Pap smear - Colposcopy, hysteroscopy, culdocentesis, LEEP - CT, MRI, US [Ordering and Interpreting Diagnostic Studies] - Diagnostic Office procedures - Wet mount - In Saline can Dx - Clue cells = BV - Trichimoniasis - In Potassium Hydroxide - Yeast infections - Fern test - Used in determination of ovulation, quality of cervical mucus in relation to sperm penetration, determination of placental insufficiency of progesterone and prediction of abortion - Non-fertile only dots and some lines appear - Transitional some fern patterns start to appear - Fertile a lot of ferning patterns appear - Schiller test - AKA VILI (visual inspection with Lugol's iodine) - Squamous epithelium contains glycogen, whereas precancerous lesions and invasive cancer contain little or no glycogen - Iodine is glycophilic and is taken up by the squamous epithelium, staining it mahogany brown or black - Columnar epithelium does not change color, as it has no glycogen - Immature metaplasia and inflammatory lesions are at most only partially glycogenated and, when stained, appear as scattered, ill-defined uptake areas - Precancerous lesions and invasive cancers do not take up iodine and appear as well-defined, thick, mustard or saffron yellow areas - Negative test squamous epithelium turns brown, columnar does not change, or irregular, partial or noniodine uptake areas appear - Positive test well defined, bright yellow iodine nonuptake areas touching the squamocolumnar junction or close to the os if SCJ not seen - Suspicious for cancer clinically visible ulcerative, cauliflower like growth or ulcer, oozing and/or bleeding on touch - Biopsy - Vulva and vagina - Cervix - Endometrium - Helpful in diagnosis of ovarian dysfunction or irregular uterine bleeding and carcinoma of uterine corpus [Trauma] - Physical assault/physical abuse (IPV) - Physical injury - Psychological abuse - Sexual assault - Reproductive coercion - Refusal to practice safe sex - Sabotage contraception - Intentional exposure to STIs - Control access to reproductive health services - Negative pregnancy outcomes - Types of IPV abuse - Physical - Verbal - Intimidation - Progressive social isolation - Deprivation of food, money, transportation, or access to health care - Phases of IPV - Tension-building - Battering - Honeymoon - Clinical findings - Physical - Acute injuries to head, abd, genitalia - Chronic Has, palpitations, abd complaints, sleep/appetite issue, pelvic pain, sexual dysfunction - Eating disorders - Somatoform disorder - Mental - Depression - Suicidal ideations - Anxiety - ETOH/substance abuse - PTSD - Differential diagnosis - Acknowledge and document trauma - Assess immediate safety - Establish a safety plan - Provide education and referrals - Management - Psychotherapy - Medication - Detoxification - Advocacy groups - Trauma in pregnancy - Abuse - Physical and psychological stress - Inadequate prenatal care - Poor nutrition/weight gain - Increased maternal behavior risks - Problems with fetal growth and development - Physical Trauma - Abrupto placentae - Preterm labor - Preterm premature rupture of membranes - Maternal/fetal injuries and demise - homicide - Sexual assault/sexual abuse - Marital rape - Acquaintance rape - Incest - Date rape - Statutory rape - Child sexual abuse - Clinical findings - Physical - Injuries - Disturbed sleeping/eating - GI irritability - MSK soreness - Fatigue/Has - Intense startle reactions - Vaginal irritation - Rectal pain/bleeding - Mental - Depression - Anxiety - Suicide attempt - Rape-trauma syndrome - PTSD - Physical Exam - Secure consent - Obtain and record the history in the patient's own words - Collect evidence (scrape material beneath fingernails, hair/dirt/underclothing/stained clothes kept as evidence) - Examine patient (note traumatized areas) - Performs a pelvic exam (collect material with cotton swabs from mouth, vagina, and anus) - Perform appropriate lab tests (GC/CT, wet mount, pregnancy test, VDRL, HIV) - Transfer labeled evidence to clinical pathologist - Note that rape and physical assault are legal terms that should not be used in medical records provider should use "consistent with the use of force" - Management - Give analgesics or sedative if indicated - Treatment for gonorrhea, chlamydia, trichomoniasis - **Ceftriaxone 125mg IM in a single dose PLUS** - **Metronidazole 2g PO in a single dose PLUS** - **Azithromycin 1g PO in a single dose** - Give emergency contraception to prevent pregnancy - Vaccinate against hep B - Offer HIV ppx - Provide source for ongoing counseling and psychological support - Violence identification and prevention - Risk factors - Prior h/o abuse - Young age - High-risk sexual behavior - ETOH/substance use - Mental illness - Less education - Unemployment - Poverty - Signs/Symptoms - Overall poor health - Unexplained injuries - Frequent ER visits - Delay in initiating care - Noncompliance - Repeated abortions - Inappropriate affect - Overly involved partners - Social isolation - Reluctance to undergo exams [Human Identity and Sexuality] - Gender Identity a person's internal sense of gender, which is independent form the sex assigned at birth - Sexual orientation refers to one's sexuality and encompasses three dimensions - Identity, behavior, and desire - Transgender - Gender identity does not correspond to birth identity - Non-binary - Someone who does no identify as exclusively a man or a woman - Cisgender - Gender identity = birth identity - Gender Fluid - Adaptable nature to the concept of gender identity and gender expression - Agender - Does not identify as having a gender - Bigender - Tendency to move between feminine and masculine gender-typed behavior depending on context - Genderqueer - Does not follow binary gender norms. They may be non-binary, agender, pangender, genderfluid, or another gender identity - Gay/Lesbian - Attracted to the same sex - Bisexual - Attracted to more than 1 sex or gender - Heterosexual/Straight - Attracted to opposite sex - Pansexual - Attracted to people regardless of their sex or gender - Queer - Attraction that is different than traditional ideas - Asexual - Not feeling sexual attraction to anyone [Physiology -- Ovaries] - Anatomical Structures - Each ovary contains thousands of follicles - Each follicle contains oocyte and layer of granuloma cells and theca cells - Supporting cells produce steroids and paracrine products - Physiologic function - Responds to gonadotropins - Produce oocytes - Produce steroid hormones - Characteristics - Have very few sensory nerves - Not visualized during physical exam [Physiology -- Fallopian Tubes] - Anatomical Structures - Connect ovaries to uterus - Open to peritoneal space - Physiologic function - Allow for movement of oocyte from ovary to uterus - Characteristics - Few sensory nerves - Not visualized during physical exams [Physiology -- Uterus] - Anatomical Structures - Endometrium - myometrium - Physiologic function - Facilitates implantation - Responds to hormonal stimulation - Endometrium - Internal hormone sensitive lining, rows differentiate and sloughs in response to levels of estrogen and progesterone - Myometrium - Smooth muscle layer, contracts leading to expulsion, expels fetus at parturition, contractions cause menstrual cramps - Characteristics - sensory nerves - Not visualized during physical exams, but palpated during bimanual [Physiology -- Cervix] - Physiologic function - Conduit for passage of menses or fetus into vagina - Characteristics - Visualized and palpated on physical exam - Earlier detection of cervical cancer (as compared to ovarian) with pap smear [Physiology -- Vagina] - Physiologic function - Muscular tube leading from cervix to vulva - Characteristics - Easily Visualized and palpated on physical exam - Frequent point of origin for infectious disease [Pathophysiology of the reproductive system] - Disordered physiological processes - Cause, result from, or otherwise associated with disease or injuries - May be affected by other systems - Neuro brain - Endocrine hypothalamus, pituitary, thyroid, adrenals - GI Liver - Renal kidneys - May affect other systems - CV dyslipidemia, HTN, preeclampsia - Endocrine DM, PCOS - MSK osteoporosis [Vagina] - Fibromuscular canal approximately 7-9 cm long - Extends from the uterus to the vestibule of the external genitalia, where it opens to the exterior - Blood supply - Vaginal branch of the uterine artery - Innervations - Contains both sympathetic and parasympathetic fibers [Vulva] - Collective term for the external part of the female genitalia - Consists of: - Mons pubis a hair-covered fat pad overlying the symphysis pubis - Labia majora rounded folds of adipose tissue forming the outer boundaries of the vagina - Originating in the mons pubis and end at the perineum - Labia minora the thinner, inner folds of skin - Extends anteriorly to form the prepuce - Clitoris homologue to the penis - 2cm in length [Bartholin's Glands] - Primary function is the production of a mucoid secretion that aids in vaginal and vulvar lubrication - The glands are located in the vulvar vestibule, at either side of the external orfice of the vagina - They become active after menarche and are non-palpable - Each gland is oval shaped and measures, on average,.5cm. - A 2 cm long efferent duct connects each gland to the posterolateral aspect of the vaginal orifice (between the hymen and the labia minora) [Vaginal Cancer] - Rare 1% of GYN malignancies and is usually secondary to other cancers (METS) - Arising from adjacent gynecologic structures: endometrium, cervix, vulva, ovary and breast) - Peak incidence at 60-65 years of age - Squamous cell represents 95%, caused by HPV - Adenocarcinoma caused by DES exposure - Also can be from melanoma or sarcoma - The most common location of vaginal carcinoma is the upper 1/3^rd^ of the posterior vaginal wall - Cancer of the vagina is usually ASYMPT. And found by abnormal cytology - Early sx painless bleeding from ulcerated tumor - Late sx bleeding, pain, weight loss, swelling - Most vaginal cancers are squamous cell - Risk Factors - Smoking - HPV infections - Multiple sex partners - h/o lower genital tract neoplasia - Clear cell variant is associated with in utero DES exposure - Most common site for vaginal cancer is the upper vagina - Diagnosis - Made by routine exam and confirmed with biopsy of the lesion via colposcopy - Differential Dx - Benign tumor (uncommon) - Ulcerative lesion from direct trauma of inflammatory reaction - Granulomatous venereal disease - Endometriosis which penetrates the cul-de-sac of Douglas into the upper vagina - Treatment - Surgery (local excision) for stage 1 lesions with consideration of radical hysterectomy, upper vaginectomy, and pelvic lymphadenectomy - Primary radiotherapy with brachytherapy for small superficial lesions - External beam radiotherapy for larger lesions - Prognosis - Size and stage of disease at time of diagnosis are most important prognostic indicators in squamous cell cancers - Vaginal tumors are staged clinically based on findings from physical and pelvic examination, cystoscopy, proctoscopy, and chest and skeletal radiography - Survival Rate at 5 years - Stage 1 77% - Stage 2 45% - Stage 3 31% - Stage 4 18% - FIGO nomenclature - Stage 1 - Carcinoma limited to vaginal wall - Stage 2 - Carcinoma has involved the subvaginal tissue but has not extended to the pelvic wall - Stage 3 - Carcinoma has extended to the pelvic wall - Stage 4 - Carcinoma has extended beyond the true pelvis or has involved the mucosa of the bladder or rectum; bullous edemas as such does not permit a case to be allotted to stage 4 - IVa tumor invades bladder and/or rectal mucosa and/or direct extension beyond the true pelvis - IVb spread to different organs [Vulvar Cancer] - Peak incidence is at 50 years old (average age 68) - Vaginal pruritis is the most common presentation (70%) - Histologic types: - Squamous cell (common) - Melanoma, basal cell carcinoma, Bartholin gland adenocarcinoma, sarcoma, and Paget disease - 90% are squamous cell cancers and melanoma - Cancer of the vulva is uncommon (4%) - Carcinoma of Bartholin's gland rare, but most common site for vulvar adenocarcinoma - Basal Cell carcinoma small elevated lesions with ulcerated center rolled edges. "Rodent ulcers" - Most arise from skin of labia major. Wide local excision necessary to prevent recurrence - Malignant Melanoma 2^nd^ most common vulvar cancer. Darkly pigmented, raised lesion is characteristic - Arises from labia minor and clitoris - May also be non pigmented or amelanotic. Excisional biopsy with wide margins for removal - Risk Factors - HPV subtypes 16, 18, and 31 pruritic black lesions - Cigarette smoking (most frequent association) - Immunodeficiency syndromes - h/o cervical cancer or dysplasia - chronic h/o vulvar irritation/pruritis (vulvar lichen sclerosis) - a family history of melanoma and dysplastic nevi anywhere on the body may increase the risk of vulvar cancer - Exam findings - Early lesions similar to chronic vulvar dermatitis - Late lesions large cauliflower appearance or hard ulcerated area of the vulva - Diagnosis - Application of acetic acid or staining with toluidine blue may help direct optimal biopsy location - Squamous cell carcinoma (most common) - Grade 1 well differentiated, forming keratin pearls - Grade 2 moderately well differentiated - Grade 3 poorly differentiated - Keratinizing type is associated with chronic vulvar irritation and older women - Warty type is associated with HPV and immunodeficiency seen in younger women - Verrucous carcinoma is a SCC variant. It resembles a mature condylomatous growth. Histopathology of base shows papillary fronds with no central core - Treatment is wide vulvectomy - Differential Dx - Epidermal inclusion cysts - Seborrheic dermatitis - Lichen sclerosis - Condyloma - Granulomatous venereal disease - Pyogenic infections - Benign tumor (granular cell myoblastoma) - Treatment - Prognosis depends on presence or absence of lymph node mets, size and location of lesion and histologic type - Lymph node status is most important prognostic variable - Surgery for staging and treatment. Complete surgical removal all tumor when possible - Common procedure is wide radical local excision with inguinal lymph node dissection - Adjuvant radiation therapy if cancer has spread to lymph nodes - Follow Up - Post op period examine q 3 months for 2 years and q 6 months thereafter to detect recurrence. Nearly 80% of recurrence occurs within the first 2 years - Prevention - The HPV vaccine can prevent the strains of HPV responsible for most vaginal, vulvar, and cervical cancer [The Ovary] - Anatomy and Function - Small, oval shaped glands - Located on either side of the uterus - Produces an ovum - Secrete hormones - Control menstrual cycle and fertility - Ovarian Cyst - A sac of fluid that form on or in an ovary, usually 1 to 2 inches wide, but they can be bigger - Common in females of reproductive age - Physiologic cysts (more common) - Follicular cyst, corpus luteal cyst - Pathologic cysts (less common) - Endometriomas, benign adult teratomas, cystadenomas, malignant neoplasms - Histology - Epithelial (most common) - Common Causes: - Ovulation or pregnancy - Dermoid cysts - Polycystic ovary syndrome (PCOS) - Endometriosis - Cancer - Diagnosis - Ultrasound - Treatment - Treat the underlying condition - Watchful waiting -- repeat ultrasound every couple of months to reevaluate the size of the cyst - OCP - Limits new cysts from growing - Surgery to remove a cyst or the whole ovary - Ruptured Ovarian Cyst - Presentation - Cyst rupture may be asymptomatic or symptomatic (Pain) - Associated with mid-cycle pain (mittelschmerz) - If symptomatic: characterized by the sudden onset of unilateral, lower abd pain - Often following strenuous physical activity (sexual intercourse, exercise) - Bleeding - Concerns - The release of cyst contents into peritoneal cavity causing irritation - Serous fluid, blood, sebaceous material - Diagnosis - Ultrasound findings of an ovarian cyst plus blood or a large amount of serous fluid in the pelvis - Differential Dx - Ectopic pregnancy, adnexal torsion, appendicitis, and tubo-ovarian abscess - Management - Uncomplicated (Most cases) -- observation - Complicated cases (ex. Hemodynamic instability, large or ongoing blood loss, signs of an infection process, findings suggestive of malignancy) may require inpatients management and/or surgery - Surgery - Laparoscopy - In a premenopausal patient with a benign ovarian cyst (physiologic or nonphysiologic) preservation of ovarian tissue via cystectomy is generally preferable to complete oophorectomy - In a postmenopausal patient, unilateral oophorectomy is generally performed; b/l salpingo-oophorectomy is only indicated if malignancy is suspected - Polycystic Ovarian Syndrome (PCOS) - An endocrine disorder affecting 5-10% of women of reproductive age - May be diagnosed when two of the following three criteria are met - Oligomenorrhea - Hyperandrogenism - Polycystic ovaries on ultrasound - Patients may present with menstrual irregularities, infertility, hirsutism, acne, obesity, ovarian enlargement, and acanthosis nigricans - Increased risk of DM, CV disease, and metabolic syndrome, nonalcoholic fatty liver disease (NASH/MASH), and endometrial cancer - Results in enlarged ovaries from multiple small follicular cysts - Clinical Features - Menstrual dysfunction - Menarche may be delayed - Oligomenorrhea (fewer than nine menstrual periods in a year) - Amenorrhea (less often) no periods for three or more consecutive months - Women often experience more regular cycles after age 40 - Hyperandrogenism - Hirsutism, acne, male pattern baldness - Elevated serum androgen concentrations (hyperandrogenemia) - Virilization signs of more severe androgen excess - Deepening of the voice and clitoromegaly (rare) - Hirsutism - Excess body hair in a male distribution - Above the upper lip, chin, periareolar area, in the midsternum, and along the linea alba of the lower abdomen - The pathophysiology of the disorder is poorly understood, but it is thought to be associated with hypothalamic pituitary dysfunction and insulin resistance - Clinical Findings - Chronic anovulation (cycle length \> 35 days) - Hyperandrogenism - Hirsutism - Alopecia - Acne - Polycystic ovaries - At least 25 small follicles - Ovarian size \> 10ml - Free testosterone - Diagnosis - Transvaginal ultrasound (TVUS) - Polycystic ovaries - May demonstrate a "string of pearls" appearance within the ovaries - Management - Polycystic ovaries themselves do no require treatment - Treat the clinical manifestations - Manage abnormal uterine bleeding, infertility, insulin resistance, obesity, and hirsutism - Other clinical manifestations - Metabolic issues/cardiovascular risks, sleep apnea - Diet and exercise are recommended for all patients - Metformin and GLP1s can help with weight loss as well as regulating menstruation - OCPs are effective in treating hirsutism and acne - Infertility is typically treated with metformin or clomiphene citrate; in rare cases ovarian cautery and laser vaporization are used - First Line treatments - Obesity/IGT - Diet and exercise - Irregular periods - Hormonal contraceptives - Metformin - DM2/IGT - Metformin - Infertility - Clomiphene citrate - Letrozole - Metformin - Hirsutism - OCPs - Spironolactone - Ovarian Cancer - Strongest known risk factor - Family history BRCA1 and BRCA2 mutations - Second most common type of GYN cancer just behind endometrial cancer - The most common cause of GYN cancer deaths in the US - Most effected population - 40-60 y/o presenting with ascites and abd pain - 75% are diagnosed at an advanced stage - Average age at Dx is 63 - If ascites is present, ovarian tumor is the most likely to be found - Protective factors for risk of ovarian cancer include multiparity, OCP use, breast-feeding, IUD and tubal ligation - Use of OCPs after 5 years decreases risk by 20%, by 15 years decreases by 50% - Risk factors - Null gravidity or infertility - Increasing age - PCOS - Early menarche - Late menopause - Endometriosis - Smoking - BRCA1/BRCA2 - 90% are epithelial tumors germ cell tumors are more common in patients less than 10 years old - Symptoms - Early stage nothing enough to seek medical attention - Late stage accounts for more than 70% of all Dxs - Increased abd girth (ascites or tumor mass) - Abd or pelvic pain, bloating - Urinary frequency or urgency - Early satiety - Exam - Pelvic exam will reveal fixed, solid, irregular adnexal mass - May show presence of ascites or upper abd mass - Abd distention is common - Differential dx - u/l cystic mass \0% but \2 to \< 10%) - 4b moderate suspicion (\>10 to \< 50%) - 4c high suspicion (\>50 to \< 95%) - 5 highly suggestive of malignancy, tissue diagnosis needed - Risk is greater than 95% - Genetic screening - USPSTF guidelines state patients with the following should be offered genetic testing for breast/ovarian cancer syndromes - Breast cancer dx before the age of 50 - Ovarian cancer dx at any age - Both breast and ovarian cancer in the same person - b/l or multiple primary breast cancers - Jewish heritage with a h/o breast and/or ovarian cancer - Presence of male breast cancer in the family - Known BRCA1/2 mutation identified in the family - Breast cancer dx prior to 60 with triple negative pathology (ER,PR, and HER2 neg) - Histologic Types - Invasive ductal MOST COMMON - Medullary - Colloid (mucinous) - Tubular - Papillary - Invasive lobular (2^nd^ most common) - Types of pathology - Estrogen receptor (ER) - Progesterone receptor (PR) - HER2 - Carcinoma of the breast types - Carcinoma of the breast in situ - Cancer is in its earliest stage and cancerous cells have not begun to spread from their site of origin - Ductal carcinoma in situ - Lobular carcinoma in situ - Increased risk of invasive breast cancer in EITHER breast - Most common type is infiltrating intraductal carcinoma (IIC) - Arise from intermediate size milk ducts - Characterized by cords and nest of cells with differing amounts of gland formations - Associated with lymphatic mets (especially axillary) - Infiltrating lobular is 2^nd^ most common -- frequently b/l - Arises from cells of the terminal milk ducts of the lobules - Characterized by small cells that insidiously infiltrate the mammary stroma and dispose tissue individually and single file pattern - Paget's disease of the nipple - Chronic eczematous itchy, scaling rash on the nipples and areola - Eczematous eruption and ulceration of the nipple - Pain, itching, burning, superficial erosion/ulceration - May have bloody d/c - Biopsy reveals intraepithelial adenocarcinoma cells or Paget cells - Inflammatory breast cancer - Rapidly progressing red, swollen, warm, itchy, thickening or dimpling of the skin (orange), results from blockage of lymphatic drainage with or without associated stromal infiltration, often with nipple retraction and there is usually no associated lump - The most aggressive form of breast cancer - IBC can easily be confused with a breast infection (mastitis), which is a more common caue of breast redness and swelling - Diffuse, brawny edema without palpable mass - Clinical Dx with confirmation through biopsy - Blockage of dermal lymph by tumor emboli - Lymphedema and hyperemia - Skin infections does not rapidly respond to abx - Generic Clinical findings - Painless mass (immobile, irregular) - Breast pain - Nipple discharge (bloody) - Nipple erosion or retraction - Redness or hardness of breast - Shrinking of the breast - Staging - T Tumor size - T1 \5cm - T4 extends to skin or chest wall - N Lymph Node - N0 no lymph mets - N1 mets to ipsilateral, movable, axillary LN - N2 mets to ipsilateral fixed axillary, or IM LNs - N3 mets to infraclavicular/supraclavicular LN, or to axillary and IM LNs - M metastasis - M0 no distant Mets - M1 distant mets - Diagnosis - Imaging - Mammo - US - MRI - CT - PET - Biopsy - FNA - Advantages removes the least amount of tissue - Disadvantages if +, doesn't allow for receptor testing and false rate occurs of about 10% - Core needle biopsy - Advantages allows for receptor testing if + - Disadvantages can leave greater deformity and large needly may miss the lesion - Open surgical biopsy - Advantages MOST ACCURATE TEST, allows for frozen section to be done followed by IMMEDIATE resection of the cancer and sentinel node biopsy - Disadvantages removes the most tissue - Labs - CBC - LFT - Beta hCG - Management - Treatment based upon TNM staging - Met workup recommended for Stage 3 and above - Early stage -- lumpectomy with Sentinel Node Biopsy and adjuvant radiation - Neg SN eliminates the need for axillary node dissection - Locally advanced -- neoadjuvant systemic therapy - Modified radical mastectomy may be needed if: - Diffuse - Large tumor - Prior radiation to the breast - Radiation post lumpectomy is contraindicated - Radiation therapy - Done after lumpectomy or past mastectomy (adjuvant therapy) to destroy residual tumor cells - External beam or brachytherapy - Surgery - Breast-conservation therapy (lumpectomy) - Radical mastectomy (breast + nipple areolar complex, pec major, pec minor, level 1,2,3 axillary nodes) - Modified radical mastectomy -- chest muscles left in place (breast + nipple areolar complex, pec fascia, pec minor +/-, Level 1,2,3 axillary nodes) - Axillary evaluation - Adjuvant Systemic Therapy - Hormonal therapy - Anti-estrogen -- tamoxifen (premenopausal) - AEs venous thrombosis, hot flashes, uterine bleeding, endometrial CA - Aromatase Inhibitors -- letrozole, anastrozole, exemestane (post menopausal) - AEs osteoporosis, VTE, MI, hot flashes, myalgias - Anti HER2/neu -- Trastuzumab - AEs cardiotoxicity (reversible DILATED cardiomyopathy) - Chemotherapy - Doxorubicin, Epirubicin, Cyclophosphamide, Fluorouracil and Docetaxel [Hormone Receptor Treatment] - Hormone receptors are proteins found inside some cancer cells. When hormones attach to hormone receptors, the cancer cells with these receptors grow - HR negative breast cancers are estrogen receptor-negative (ER-neg) and progesterone receptor-negative (PR-neg). these cancers do not express hormone receptors - This means they have FEW or NO hormone receptors - HR positive breast cancers are estrogen receptor-positive (ER-positive) and progesterone receptor-positive (PR-positive). These cancers express hormone receptors - This means they have A LOT of hormone receptors - ER and PR positive tumor - Treatment will include hormone therapy (such as tamoxifen or an aromatase inhibitor) - Tamoxifen binds and blocks estrogen receptor in the breast tissue - Aromatase inhibitors are used in post menopausal women which reduces the production of estrogen - Prevents cancer cells from getting the hormones they need to grow and may stop tumor growth - ER and PR negative tumor - Current hormone therapies are designed to treat ER positive cancers, these cases are treated the same as breast cancers that are positive for both hormone receptors - Hormone receptor negative breast cancers are not treated with hormone therapy [HER2 Status] - HER2 (human epidermal growth factor receptor 2) - Protein that appears on the surface of some breast cancer cells - May also be called HER2/neu or ErbB2 - Its an important part of the pathway for tumor cell growth and survival - Testing - Immunohistochemistry (IHC) which detects the amount of HER2 protein on the surface of the cancer cells - Score is 0 or 1+ tumor is HER2 negative - Score is 2 + results are unclear and should be confirmed by FISH - Score is 3+ tumor is HER2 positive - Fluorescence in situ hybridization (FISH), which detects the number of HER2 genes in the cancer cells - Negative (non-amplified) tumor is HER2 negative - Positive (amplified) tumor is HER2 positive - Treatment - HER2 positive cancers can benefit from HER2 targeted therapies, such as trastuzumab (Herceptin), which directly target the HER2 receptor - Binds to the extracellular portion of the HER2 gene - Prevents the expression of growth factors - Also induces apoptosis through antibody-dependent cellular cytotoxicity - Trastuzumab and other HER2-targeted therapies are not used to treat HER2-negative cancers - If the tumor is HER2-negative, ER-negative, and PR-negative, you may see the tumor described as TRIPLE NEGATIVE BREAST CANCER - The worst prognosis [Primary Breast Cancer] - Prevention in high-risk groups - Risk factors - 65 or older with 1 1^st^ degree relative with breast cancer - 45 or older with more than 1 1^st^ degree relative with breast cancer or 1 first degree relative who developed breast cancer before age 50 - 40 or older with a 1^st^ degree relative with b/l breast cancer, presence of atypical ductal or lobular hyperplasia or lobular carcinoma in situ on a prior biopsy - When considering prescribing breast cancer risk-reducing meds, the potential benefit of risk reduction of breast cancer must be balanced against the potential harms of adverse medication effects - SERM (selective estrogen receptor modulators) - Tamoxifen and raloxifene - Preferred in postmenopausal with osteoporosis - Treatment is usually for 5-10 years - Tamoxifen is preferred but increased risk of DVT and uterine CA is possible - Lymphedema - Occurs because of lymphatic disruption and insult - Caused primarily by local treatment modalities like surgery and radiation - Level 1 and 2 axillary lymph node dissection and radiation -- the risk of lymphedema is roughly \< 10% - Level 3 dissection risk approaches 30% - Lymphedema rates now are lower with the advent of Sentinel Lymph Node Biopsy [Breast Reconstruction after Mastectomy] - TRAM flap - A flap of this skin, fat, and all or part of the underlying rectus abdominus muscle are used to reconstruct the breast - TRAM flap tissue is very similar to breast tissue and makes a good substitute - Downside of TRAM flap surgery is that it involves cutting through muscle - DIEP flap - Deep interior epigastric perforator flap surgery is a newer procedure - Spares the muscle and has fewer risks and complications than TRAM flap surgery - They take the same skin and fat that they'd use in a TRAM flap and only the blood vessel that feeds the skin and fat [Life Long Follow UP] - Recommendation - Physical examination - Every 3-6 months for the first 3 years - Then every 6-12 months until year 5 - Annually thereafter - Mammogram - Annually for all patients and no less than 6 months after the completion of radiation therapy - Routine lab tests not recommended for routine surveillance - Routine bone scans or additional imaging not indicated unless the patient is symptomatic or there is clinical suspicion of an abnormality - Patients taking tamoxifen - Annual pelvic examinations - Counseled to report any irregular vaginal bleeding - Patients on Ais need periodic bone density studies and lipid panels to assess their cardiovascular risk factors