Gynecology
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| Spontaneous bloody, serous, or cloudy nipple discharge | Intraductal papilloma
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| Breast mass, nipple retraction, bloody nipple discharge | Breast cancer (mass is most common presenting clinical manifestation)
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| Br Ca: estrogen receptors | All invasive lobular and 2/3 of ductal ca are est rec pos
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| Br Ca typical presentations | single nontender firm immobile mass; 45% in UOQ, 25% nipple
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| Br Ca increases risk of: | endometrial ca, and vice versa
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| Breast exam: lymph nodes | Axillary, supraclavicular, and infraclavicular lymph nodes
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| Polythelia = | supernumerary nipples
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| Duct ectasia = | widening of breast ducts; in pts near/past menopause; thick sticky discharge and/or itching around nipple
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| Fat necrosis | Firm round lump; often d/t MVA or trauma
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| Most common breast complaint = | mastalgia (benign breast pain); assoc w/hormonal changes; teens & 40s, usu ends w/menopause
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| Most common benign breast tumor: | Fibroadenoma: hormone influenced abnormal growth of fibrous & ductal tissue. AA women; teens/20s; rapid growth during PG
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| Fibroadenoma assessment | Discrete lump: firm, rubbery, round, mobile, non-tender, smooth, solitary. Usually in UOQ, 1-5 cm
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| Peau d'orange is associated with: | Inflammatory breast ca
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| Ductal BrCa types | In Situ; Invasive; Inflammatory
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| Lobular BrCa types | In situ; Invasive, predominantly in situ; Invasive
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| Nipple BrCa types | Paget disease with intraductal carcinoma. Paget disease with invasive ductal carcinoma
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| Mastalgia: firstline tx | Sports bra, NSAIDs, reduce caffeine & fat in diet, warm compress, avoid premenstrual Na
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| Fibroadenoma Tx | Excision of mass; monitor
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| mastodynia tx | reassurance, vit B6, bromocriptine, tamoxifen, or danazol
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| mastitis tx | cloxacillin, dicloxacillin, or nafcillin; or ceph. May continue breastfeeding
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| Breast cancer mgmt | lumpectomy = mastectomy (partial or radical) re: survival, if f/u w/xrt; poss adjuvant CT; tamoxifen if est-rec pos or postmenopausal
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| 30 – 50 yo female, painful, multiple, bilateral breast masses that increase in pain and size before menses = | Fibrocystic breast disease
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| Mammography: when (ACS) | 20-39 yo: q 3 yrs; annual at 40 (average risk); high risk: 5 yrs before age of 1st degree relative dx; individualize for older pt
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| Mammography: when (USPSTF) | 50-74: biennial; <50: individual
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| CBE: PE | Dimpling; Color changes; Retraction; Skin thickening; Pronounced/ recent asymmetry; Spontaneous nipple discharge
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| BSE recommendations | ACS: BSE is an option starting in pts' 20s; USPSTF: Grade D (no benefit)
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| Mastalgia: secondline tx | Suppress ovulation
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| Most common benign breast condition: | Fibrocystic changes; grainy, palpable, small lumps; 30-50 y.o.; mobile, well defined; bilateral, UOQ; tender last half of cycle; dx w/bx
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| If find mass on CBE: | Order a diagnostic mammogram (not screening), unless age <30, then order U/S
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| Fibroadenoma may grow rapidly during: | pregnancy
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| Fibroadenoma Dx | FNA; Cyto study of bloody fluid or solid tumor aspirate; U/S to differentiate solid from cystic mass; definitive dx by excisional bx and tissue exam
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| Paget dz of breast: progression | Begins in breast duct and spreads to nipple and areola; usually occurs w/ infiltrating ductal breast cancer
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| BrCa RF | Genetics (BRCA1&2). FH; PMH/SH, prior abnormal breast bx. Diet may reduce risk. Age (60 yo ave onset). Nulliparous, early menarche, late menopause, delayed childbearing. LT estrogen
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| BrCa Lifestyle factors | No kids/lactation; HRT; Mod to heavy alcohol; Obesity/ high fat diet; Sedentary lifestyle; OCP use?
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| Malpractice suits: due to failure to: | recommend screening; follow-up on or verify woman’s complaints; follow-up on an abnormal clinical breast exam
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| Age <30 yo, palpable lump, still there after menses, order: | unilateral breast U/S
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| Age > 30yo, palpable lump, order: | Unilateral dx mammogram & U/S. If c/w fibroadenoma, FNA or aspiration: excision if change in lesion
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| Palpable lump, age > 40 yo & due for screening mammo: | get mammogram on unaffected side at same time
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| BI-RADS category 0-4: | Needs additional imaging evaluation
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| BI-RADS category 4: | Suspicious abnormality
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| BI-RADS category 6: | biopsy-proven malignancy
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| Women at high risk (greater than 20% lifetime risk) should get: | an MRI and a mammogram every year
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| Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is: | less than 15%
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| Congestive breast disorder clinical features | bilateral breast pain / swelling (2/2 engorgement) 2-3 days postpartum, low fever, axillary LAD
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| Mastitis clinical features | Unilateral breast pain, fever, chills, tender, erythema, 1 week postpartum.
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| Clinical breast exam | At least Q3 years in pt 20-39 yo, annually after 40 yo
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| Mammogram guidelines | USPSTF: baseline at 50 yo, then QOYr until 74 yo. Begin at age 40 only in pt with RF. ACS: annual starting at 40 yo
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| BrCa Risk Factors | >50 yo. PMHx or FH BrCa. BRCA 1 or 2 gene. Postmenopausal obesity. EtOH. Early menarche / late menopause. Nulliparity >30 yo
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| Fibrocystic disease sx/sx | Bilateral breast involvement; multiple smooth lumps +/- discharge
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| Polypoid epithelial tumors arising in ducts = | Intraductal papilloma (usually solitary; diffuse lesions have increased risk of BrCa)
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| Stromal tissue with epithelium-lined ductlike structures and absence of elastic tissue = | Fibroadenoma
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| Br Ca stats | 11% of US women. AA>white if <40 yo, reversed >40 yo. Whites higher incidence but AA higher mortality. Most are invasive adenocarcinomas: 80% infiltrating intraductal, 10% infiltrating lobular
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| Types of infiltrating intraductal Br Ca | Papillary, intraductal, medullary
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| Br Ca mets | Spread by vascular and lymphatic routes. Adenocarcinomas to bones, lungs, liver, brain. Lobular to meninges, peritoneum, pleura, ovaries, mediastinal, retroperitoneal LNs
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| Br Ca workup | Mammogram. MRI for high-risk pt. FNA. Open bx is definitive. Resection of primary tumor & ipsilateral LN for staging. CXR, bone scan, CT for further dx
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| Br Ca mgmt | Lumpectomy vs mastectomy; +/- post-op XRT. Hormonal tx in mets dz or adjuvant (tamoxifen) in early dz in postmenopausal. Targeted therapy (trastuzumab, lapatinib) in HER2-positive dz. Bisphosphonates for bony mets pain
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