Devirgilio Pt II Flashcards
H and P for breast mass?
New breast mass in a postmenopausal woman is cancer until proven otherwise
Breast cancer is firm with irregular borders
Types of nipple discharge that are more concerning for cancer?
Bloody, spontaneous, unilateral, uniductal, associated with breast mass, in women over 40
Risk factors for breast cancer?
Family history, genetic defects (BRCA 1 2) obesity, early menarche, late menopause, nulliparity, childbirth after age 30, alcohol, radiation to chest before age 30
Most common causes: palpable breast mass? malignant neoplasm? benign neoplasm?
Palpable: fibrocystic disease
Malignant: Invasive ductal carcinoma
Benign: fibroadenoma
Rate of breast cancer in US? What receptors are absent in triple-negative?
Rate: 1 in 8 women
Triple negative: Progesteron, estrogen, HER-2
What is the work up for new breast masses?
Triple-test:
physical exam, imaging, tissue sample
What imaging is appropriate for breast masses?
Less than 30 yo: Ultrasound
Over 30 yo: Ultrasound plus Mammogram
Tissue sampling that distinguishes in situ from carcinoma?
Core needle biopsy
FNA cannot distinguish between the two
Metastatic work up for clinically early breast cancer?
CXR, liver chemistries, alkaline phosphatase
Additional metastatic work up if high suspicion? What makes high suspicion?
Bone scan, CT abdomen, chest and brain
Suspicion based on: lab tests, clinical stage 3 disease or symptoms
Management for early stage breast cancer?
1) Lumpectomy, SLNB, and radiation (BCT)
- Higher local recurrence rate
- Equal survival with 2
or
2) Simple mastectomy with SLND
- no radiation if early stage, but needed if more advanced
What is SLNB?
Sentinel Lymph Node Biopsy
2-4 nodes
Less lymphedema than ALND
May need ALND if positive for metastasis
Management for stage III cancer?
Treatment is individualized:
Inflammatory breast cancer: neoadjuvant chem followed by radical mastectomy, then radiation
For large tumors, BCT is not an option
For clinically positive axillary lymph nodes, SLNB is not an option, use ALND
What drugs are used for HER-2 positive? Premenopausal ER positive? Postmenopausal ER positive?
HER-2: Trastuzumab
Premenopausal ER: Tamoxifen
Postmenopausal ER: Anastrozole (aromatase inhibitor)
Who does not receive chemotherapy in breast cancer?
Small tumors (1- cm) with favorable hormonal and molecular characteristics and SLNB negative
Complications from breast cancer surgery?
Axillary lymph node dissection can lead to significant morbidity: Lymphedema, nerve injury (long thoracic, thoracodorsal, medial, lateral pectoral nerves)
4 watch outs in breast cancer?
Men can get breast cancer
Do not confuse inflammatory breast cancer with cellulitis
Do not ignore breast masses in pregnancy or in younger women
Always obtain a tissue diagnosis if there is a palpable breast mass, do not be fooled by a normal mammogram
What is one feature on mammography that helps differentiate between benign and malignant conditions?
Size of calcifications:
Macro calcifications are almost always benign
Micro calcifications are more often associated with malignancy
S/sx of endocarditis? Associated conditions? Risk factors?
S/sx: Fever, new murmur, positive blood cultures, Laneway lesions (non-tender lesions on palms and soles) Osler nodes (tender lesions on digits)
Associated: Aortic regurgitation (widened pulse pressure)
Risk factors: Rheumatic heart disease, congenital anomalies (mitral valve prolapse), IV drug use
Risk factors for aortic dissection?
hypertension, connective tissue disease (Marfan’s, Ehler’s Danlos, etc), advanced age, atherosclerosis, pregnancy, cocaine use, aortic injury (trauma/catheter), bicuspid aortic valve, aortic coarctation
Marfan’s: inheritance pattern, defect, protein, function in aortic dissection?
Inheritance: autosomal dominant
Defect: misfolded proteins
Protein: fibrillin
Function: misfolded fibrillin results in cystic medial necrosis of large vessels, weakening the wall
Classification schemes for aortic dissection?
Stanford A & B: A involves the ascending aorta with or without the descending, B involves only the descending after the left subclavian artery.
DeBakey I, II, III: I - entire aorta (ascending and descending) II - only ascending, stopping before the R carotid, III - only descending, starting after the L subclavian
Most common type of aortic dissection?
Most common type is Stanford B (descending only), but Marfan’s patients most commonly PRESENT with Stanford A.
Life threatening complications of Stanford A dissections?
Interrupted coronary arteries = MI
Interrupted carotid arteries = ischemic stroke
May also dissect into the pericardial sac = acute tamponade