GUM + Breast Flashcards

Question

How does chlamydia spread within the body to infect you?

Answer 1

C. trachomatis enters the host cell as an elementary body (infectious form). Once inside the cell it becomes a reticular body, the non-infectious form capable of replication. Following replication, these reticular bodies mature back to elementary bodies, and following cell rupture the elementary bodies infect other cells resulting in inflammation and tissue damage.

Answer 2

a sexually transmitted infection caused by serovars L1, L2 or L3 of Chlamydia trachomatis. L2 is most common

Answer 3

Men who have sex with men 99% of cases are in this group Often co-infection with HIV

Answer 4

The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected. If they're matted together or suppurative, which is termed a buboe. The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion.

Answer 5

Typically identified on the coronal sulcus of the glans penis in men or posterior vaginal wall and/or vulva in women. Painless papule Painless pustule Painless shallow ulcer Proctitis Rectal pain Rectal bleeding Rectal discharge Tenesmus Secondary stage: Lymphadenopathy: inguinal/femoral, typically unilateral and painful Lymphadenitis: infected lymph nodes Buboes: marked lymphadenitis that becomes suppurative. At risk of chronic fistulae formation Groove sign (15-20%): femoral and inguinal lymphadenopathy are separated by the inguinal ligament Systemic upset: rarely fever, pneumonitis, hepatitis, aseptic meningitis or arthritis can occur Tertiary stage: Proctitis/proctocolitis: bleeding, pain, tenesmus Fistulae Strictures Chronic lymphoedema

Answer 6

NAAT: Genital swab: ideally taken from base of an ulcer Rectal swabs Urethral swab First-catch urine Aspiration from lymph nodes: often utilised in presence of buboes Also refer to GUM for full STI screen

Answer 7

Oral doxycycline 100 mg twice daily for 21 days or tetracycline 2g daily for 21 days (2nd line is azithromycin or erythromycin) Abstinence and all sexual contacts within 4 weeks of symptomatic LGV or 3 months of asymptomatic carriage of LGV will need to be contacted, screened and receive empirical treatment.

Answer 8

Neisseria gonorrhoeae is a gram-negative diplococcus bacteria. It infects mucous membranes with a columnar epithelium, such as the endocervix in women, urethra, rectum, conjunctiva and pharynx. It spreads via contact with mucous secretions from infected areas. Common in MSM.

Answer 9

Infection with gonorrhoea is more likely to be symptomatic than infection with chlamydia. Odourless purulent discharge, possibly green or yellow Abnormal bleeding Tender lymph nodes Dysuria Dyspareunia Pelvic pain Testicular pain or swelling Rectal, pharyngeal and conjunctival infection can also occur Rarely there is disseminated infection - tendinitis, tenosynovitis, septic arthritis, meningitis and endocarditis

Answer 10

Nucleic acid amplification testing (NAAT) - endocervical, vulvovaginal or urethral swabs, or in a first-catch urine sample. Rectal and pharyngeal swab are recommended in all men who have sex with men (MSM), and in those with risk factors Charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics.

Answer 11

presence of monomorphic Gram-negative diplococci within polymorphonuclear leukocytes

Answer 12

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 13

NAAT testing if they are asymptomatic, or cultures where they are symptomatic 72 hours after treatment for culture 7 days after treatment for RNA NAAT 14 days after treatment for DNA NAAT

Answer 14

Advise to abstain from sex for seven days of treatment of all partners to reduce the risk of re-infection Test for and treat any other sexually transmitted infections Provide advice about ways to prevent future infection Consider safeguarding issues and sexual abuse in children and young people

Answer 15

Pelvic inflammatory disease Chronic pelvic pain Infertility Epididymo-orchitis (men) Prostatitis (men) Conjunctivitis Urethral strictures Disseminated gonococcal infection Skin lesions Fitz-Hugh-Curtis syndrome Septic arthritis Endocarditis Higher risk of getting HIV Neonatal conjunctivitis - emergency

Answer 16

Mycoplasma genitalium (MG) is a bacteria that causes non-gonococcal urethritis. It is a sexually transmitted infection. There are developing problems with antibiotic resistance, particularly with azithromycin. Most cases of MG do not cause symptoms. The presentation is very similar to chlamydia, and patients may be infected with both organisms. Urethritis is a key feature.

Answer 17

Urethritis Epididymitis Cervicitis Endometritis Pelvic inflammatory disease Reactive arthritis Preterm delivery in pregnancy Tubal infertility

Answer 18

Traditional cultures are not helpful in isolating MG, as it is a very slow-growing organism. Therefore, testing involves nucleic acid amplification tests (NAAT) First urine sample in the morning for men Vaginal swabs (can be self-taken) for women Check for macrolide resistance and do test of cure

Answer 19

Doxycycline 100mg twice daily for 7 days then Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides) Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Answer 20

Trichomoniasis is a curable sexually transmitted infection (STI) caused by the protozoan Trichomonas vaginalis (TV). Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. The flagella are used for movement, attaching to tissues and causing damage.

Answer 21

Trichomoniasis is the most common non-viral sexually transmitted infections worldwide but it's relatively rare in the UK

Answer 22

infect squamous cells of the urogenital epithelium. It most commonly infects areas of the vagina and urethra. Other sites of infection include the cervix, bladder, Bartholin glands, and prostate. Humans are the only known reservoir for T. vaginalis and it is almost always sexually transmitted. The Protozoa can be transmitted between women and men, women and women, but rarely between two men. Co-infection with other conditions is common

Answer 23

Multiple sexual partners Unprotected sexual intercourse A history of other STIs Older women are more at risk of TV

Answer 24

Asymptomatic Vaginal discharge: frothy, green-yellow Vulval itching or soreness Malodorous Dysuria Dyspareunia Urethral discharge in men Urethral irritation Abdominal pain Cervical inflammation (often described as ‘strawberry cervix’ = colpitis macularis, caused by tiny haemorrhages on the cervix) Rarely balanitis or balanoposthitis (inflammation of glans penis and foreskin)

Answer 25

- pH > 4.5 - The diagnosis can be confirmed with a standard charcoal swab with gram staining, microscopy and culture from the posterior fornix of the vagina in women. A self-taken low vaginal swab may be used as an alternative. - NAAT - Rapid antigen test - Cytology - can be incidental on smears - A urethral swab or first-catch urine is used in men Screen for other STIs

Answer 26

Oral metronidazole. Either 400–500mg twice a day for 5–7 days, or 2g as a single oral dose Advise abstinence for at least one week, and until the person and all partners have completed treatment Screening for other sexually transmitted infections Contact tracing

Answer 27

Contracting HIV by damaging the vaginal mucosa Bacterial vaginosis Cervical and prostate cancer Pelvic inflammatory disease Pregnancy-related complications such as preterm delivery.

Answer 28

a sexually transmitted infection caused by the Herpes simplex virus 1&2. 1 also affects mouth and nose and is the most common in the UK. It is transmitted via skin-to-skin contact through vaginal, anal or oral sex. Once infected people may be asymptomatic for a long period of time, until the first flare up. Following the primary symptomatic infection, the virus can lie dormant until it recurs later in life causing recurrent outbreaks.

Answer 29

HSV enters the body through small cracks in the skin or through the mucous membranes of the mouth, vagina, rectum, urethra or under the foreskin. After infecting the surface, the virus travels up the nearest nerve to the ganglion and remains there. Asymptomatic shedding is also an important cause of transmission as many people can shed and transmit the virus even if they are unaware they have the infection.

Answer 30

Oro-labial herpes: trigeminal ganglia Anogenital herpes: sacral nerve root ganglia

Answer 31

Asymptomatic Painful vesicle, pustule or ulceration: usually multiple lesions of different ages Vaginal/urethral discharge Dysuria Systemic symptoms: fever, headache, malaise, myalgia (more common in primary infection) Proctitis: bleeding, tenesmus, pain, discharge (more common in MSM) Vesicles Pustules Ulceration: usually evidence of crusting over Lymphadenopathy/lymphadenitis (inguinal): usually tender and bilateral. Seen in around 30%. Unilateral more common in recurrent infection Urinary retention: if pelvic autonomic nerves affected

Answer 32

Once primary infection has cleared the virus remains dormant in the body. It can reactivate causing recurrent outbreaks. These are shorter and less severe and over time reduce in severity and length bcos of antibody production. Usually presents with burning, itching and painful red blisters around the genitals.

Answer 33

Superinfection (lesions may become infected by bacteria or fungi), Autonomic neuropathy (urinary retention), Autoinoculation (lesions can be passed to other areas of skin through direct contact), CNS complications (aseptic meningitis and encephalitis but more likely in patients with HIV co-infection or marked immunosuppression), hepatitis, oesophagitis, keratitis, etc

Answer 34

NAAT from base of the ulcer Other STI screen Serology for antibodies

Answer 35

Acyclovir Abstain Salt baths Analgesia (topical lidocaine 2% gel e.g. Instillagel and paracetamol) Loose clothing Refer to GUM

Answer 36

No but there is a worry of transmission causing neonatal herpes simplex infection through delivery. Management depends on whether it is first episode or recurrent. Primary before 28 weeks = aciclovir then regular prophylactic aciclovir starting from 36 weeks gestation onwards to reduce the risk of genital lesions during labour and delivery. Women that are asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection). Caesarean section is recommended when symptoms are present. Primary after 28 weeks = aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. Caesarean section is recommended in all cases to reduce the risk of neonatal infection. Recurrent carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.

Answer 37

Treponema pallidum. This bacteria is a spirochete, a type of spiral-shaped bacteria. The bacteria gets in through skin or mucous membranes, replicates and then disseminates throughout the body. It is mainly a sexually transmitted infection. The incubation period between the initial infection and symptoms is 21 days on average.

Answer 38

Oral, vaginal or anal sex involving direct contact with an infected area Vertical transmission from mother to baby during pregnancy Intravenous drug use Blood transfusions and other transplants

Answer 39

a papule will appear before ulcerating into a chancre. A chancre is a painless ulcer and typically develops 9-90 days post infection on a genital site. Usually singular, hard and non-itchy. However, chancres may be atypical in that they can appear at other sites e.g. oral, be multiple and painful. Classically chancres heal within 3-10 weeks with or without symptoms but may persist during secondary syphilis.

Answer 40

Occurs 4-10 weeks after primary infection. It typically presents with a maculopapular symmetrical rash on the palms, legs, soles and face which is not itchy or painful. There also may be fever, malaise, arthralgia, weight loss, headaches and painless lymphadenopathy. Other less common features include malaise, fever, hepatitis, glomerulonephritis and neurological complications. Condylomata lata- elevated plaques like warts at moist areas of skin e.g. inner thighs, anogenital region, axillae Moth eaten alopecia Mucus patches (snail tract lesions) Silvery-gray mucous membrane lesions – oral, pharyngeal, genital

Answer 41

Latent syphilis occurs after the secondary stage of syphilis, where symptoms disappear and the patient becomes asymptomatic despite still being infected. Early latent syphilis occurs within two years of the initial infection, and late latent syphilis occurs from two years after the initial infection onwards.

Answer 42

Can occur many years after the initial infection and affect many organs of the body as gummatous, cardiovascular or neurological syphilis.

Answer 43

Granulomas can form in bone, skin, mucous membranes of the upper respiratory tract, mouth and viscera or connective tissue e.g. lung, liver, testis. Patients at this stage are non-infectious. Signs and symptoms vary according to the tissue affected.

Answer 44

Tabes dorsalis – ataxia, numb legs, absence of deep tendon reflexes, lightning pains, loss of pain and temperature sensation, skin and joint damage. Dementia – cognitive impairment, mood alterations, psychosis. Meningovascular complications – cranial nerve palsies, stroke, cerebral gummas. Argyll Robertson pupil – pupil is constricted and unreactive to light, but reacts to accommodation.

Answer 45

Aortic regurgitation due to aortic valvulitis (diastolic murmur), also aortic root dilatation. Angina due to stenosis of the coronary ostia. Dilation and calcification of the ascending aorta.

Answer 46

Early: presenting < 2 years after birth. Typically presents with rash, haemorrhagic rhinitis ('bloody snuffles'), lymphadenopathy, skeletal changes and hepatosplenomegaly. Many other features can be present. Late: presenting > 2 years after birth. Persistent inflammation predominantly affects bones and teeth leading to characteristic features.

Answer 47

Saddle nose: nasal septum destruction Saber shins: bowing of tibia from chronic inflammation Clutton’s joints: symmetrical joint swelling. Most commonly the knees Hutchinson’s teeth: widely spaced and notched upper incisors Mulberry molars: molar teeth with too many cusps

Answer 48

Dark ground microscopy of chancre fluid- detects spirochaete in primary syphilis PCR testing of swab from active lesion Serology: - Treponemal tests – assess for exposure to treponemes (NB not necessarily syphilis) 1. Treponemal ELISA (IgG/IgM) – remains positive for life 2. TPPA or TPHA – remain positive for life - Non-treponemal tests: RPR/VDRL: rises in early disease; falling titres indicate successful treatment or progression to late disease. False positives can occur in inflammatory conditions or during pregnancy. - Lumbar puncture: CSF antibody tests in neurosyphilis

Answer 49

non-specific but sensitive tests used to assess for active syphilis infection. These tests assess the quantity of antibodies being produced by the body to an infection with syphilis. A higher number indicates a greater chance of active disease. These tests involve introducing a sample of serum to a solution containing antigens and assessing the reaction. A more significant reaction suggests a higher quantity of antibodies. The tests are non-specific, meaning they often produce false-positive results.

Answer 50

A positive EIA with a non reactive RPR and a non reactive TPPA is a most likely a false positive EIA result. If clinical history suggests a risk for syphilis the EIA should be repeated in 3-4 weeks. A positive EIA with a non reactive RPR and a positive TPPA is consistent with treated syphilis. The diagnosis should not be made on the basis of one clinical test result. The entire clinical picture should be considered, including symptoms and history.

Answer 51

Full screening for other STIs Advice about avoiding sexual activity until treated Contact tracing Prevention of future infections A single deep intramuscular dose of benzathine benzylpenicillin (penicillin) is the standard treatment for syphilis. Other drugs may need to be added depending on the stage.

Answer 52

The Jarisch-Herxheimer reaction is a potential reaction to penicillin treatment in syphilis infection, characterised by fever, rash, rigors and tachycardia. It is thought that as the bacteria are lysed by the antibiotic, they secrete an endotoxin which can cause an inflammatory response

Answer 53

Supportive measures are all that is required, unless a patient has cardiovascular or neurosyphilis, in which case oral steroids should be administered prior to antibiotics to reduce the risk of an acute localised inflammatory reaction.

Answer 54

Chancroid is an infection of the genital skin caused by Haemophilus ducreyi. It is a highly infective gram negative bacilli and typically produces a painful, potentially necrotic genital lesion. Associated symptoms include painful lymphadenopathy and bleeding on contact.

Answer 55

- Painful papules: early lesion that deteriorates into pustule then ulcer. - Ulcers: typically deep, painful and purulent with a ragged edge. Easily bleed when touched - Painful and unilateral inguinal lymphadenopathy - Buboe: infected, painful lymphadenitis that ulcerates and becomes suppurative. Can cause chronic draining sinuses.

Answer 56

Microscopy and culture NAAT Serology Ask about travel history to tropical areas and greenland

Answer 57

GUM referral Abstain Contact tracing Single dose of Azithromycin 1 g orally or Ceftriaxone 500 mg IM. In HIV patients ciprofloxacin or erythromycin are preferred.

Answer 58

Genital warts are caused by human papilloma virus, with 90% being caused by serotypes 6 and 11. They are spread by skin to skin contact causing cauliflower-like lesions known as condylomata, which are typically painless and occur on moist surface

Answer 59

painless lumps which are either keratinised or non-keratinised. They present on areas that are traumatised during sexual intercourse. Can also be asymptomatic, new growth or lump, local irritation, bleeding and discomfort around the lesion

Answer 60

Usually a clinical diagnosis after examination Refer to GUM for full STI screen Atypical lesions that do not respond to treatment should be biopsied in case of malignancy

Answer 61

Advise to use condoms, stop smoking, get current partner tested but contact tracing isn't needed, psychological counselling may be needed - Topical agents: Podophyllotoxin cream 0.15%, Imiquimod cream 5%, trichloroacetic acid (TCA) - Surgical intervention: Cryotherapy, Electrocautery, Excision - Other: 5-Fluorouracil, interferon therapy, laser or photodynamic therapy

Answer 62

Molluscum contagiosum is caused by the molluscum contagiosum virus (MCV), a member of the the poxvirus family. It is transmitted by skin to skin contact.

Answer 63

The lesions can be described as small, smooth, pearly coloured papules with a central area of umbilication They can occur anywhere on the body, but commonly occur on the genitals. In immunocompromised patients, lesions can be found to be extra-genital, particularly on the face Diagnosis is made using visual inspection plus full STI screen.

Answer 64

It is usual for the infection to clear spontaneously within 18 months, however if the patient is caused distress due to cosmetic reasons, the patient may be offered cryotherapy to remove the lesions.

Answer 65

Klebsiella granulomatis, higher incidence in tropical countries like Papua New Guinea. Beefy red papules/nodules, ulcers, lymphadenopathy and lymphoedema Usually a clinical diagnosis but can be confirmed with a tissue sample showing Donovan bodies. Plus full STI screen. Managed with 3 week course of Azithromycin

Answer 66

Pubic lice infection by Phthirus pubis (crab louse), usually seen in teens and young adults Direct contact with an infected areas (genital region or contaminated clothing) leads to transmission. Pruritus, visible lice, small bluish macules due to prolonged infestation and injection of natural anticoagulant from lice saliva during feeding and lymphadenopathy (rarely) Ix - direct visualisation with naked eye or microscopic exam plus full STI screen Mx - nit comb, abstain, contact tracing, wash bedding and use permethrin 1% cream.

Answer 67

It is the most common malignancy in women, affecting 1 in 8 women

Answer 68

Female gender Age Family history Personal history of breast cancer Genetic predispositions (e.g. BRCA 1, BRCA 2) Early menarche and late menopause Nulliparity Increased age of first pregnancy Multiparity (risk increased in period after birth, then protective later in life) Combined oral contraceptive (still debated, effect likely minimal if present) Hormone replacement therapy White ethnicity Exposure to radiation

Answer 69

BRCA 1: Caused by a mutation on chromosome 17 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 65-80% whilst the risk of ovarian cancer is 40-45%. More likely to give high grade triple - BRCA 2: Caused by a mutation on chromosome 13 that predisposes patients to breast cancer amongst other malignancies. The lifetime risk of breast cancer is approximately 45-70% whilst the risk of ovarian cancer is 11-25%. More likely to give oestrogen and progesterone receptor tumours. Men w BRCA 2 have higher risk than men w BRCA 1. Also increases risk of other cancers; peritoneal, endometrial, fallopian, pancreatic and prostate cancer. Others: TP53 (Li-Fraumeni syndrome). PTEN, MLH1, MLH2, and STK11.

Answer 70

Most common form of breast tumour (75%) Abnormal proliferation of ductal cells The grade is considered higher as the ductal cells lose their acinar structure and their nuclei become abnormally large If the basement membrane is NOT BREACHED then it is considered ductal carcinoma in situ (DCIS) - good prognosis

Answer 71

comedo, cribriform, micropapillary, papillary, and solid types, however most lesions are mixed.

Answer 72

Just as with ductal carcinomas, it can be in situ or invasive Makes up about 15% of breast cancers More likely to be bilateral and multi-centric Abnormal proliferation of lobular cells, which arrange themselves in single rows. Due to the sparse distribution of the tumour cells, they are frequently impalpable or not appreciable as a discrete lump If the basement membrane is NOT BREACHED then it is considered lobular carcinoma in situ (LCIS). These are frequently multifocal and impalpable. Not very common.

Answer 73

Luminal A Luminal B Basal HER2

Answer 74

More common in younger patients and those with BRCA1 mutations Composed of solid sheets of anaplastic cells with large pleomorphic nuclei, prominent nucleoli and frequent mitoses There is also often significant lymphocytic infiltration surrounding the tumour Often has a better prognosis than ductal tumours.

Answer 75

This is rare (1% of breast tumours) Composed of epithelial and stromal tissue which grows in a “leaf-like" pattern Also called cystosarcoma phyllodes Can mimic fibroadenoma but grows faster and is seen in older women Most (75%) are benign, with 25% being malignant

Answer 76

This is rare (1% of breast tumours) Composed of epithelial and stromal tissue which grows in a “leaf-like" pattern (fibroepithelial tumour) Also called cystosarcoma phyllodes Can mimic fibroadenoma but grows faster and is seen in older women (40/50) Most (75%) are benign, with 25% being malignant

Answer 77

Commonly present with a smooth, hard, palpable breast mass which may sometimes be seen as a smooth bulge under the skin of the breast In advanced cancer, may present with an ulcer on the breast Can be aggressive and can grow quickly to a very large size (although they rarely metastasise).

Answer 78

Phyllodes affects older women and progresses more rapidly

Answer 79

1-3% of breast cancers Presents similarly to a breast abscess or mastitis Swollen, warm, tender breast with pitting skin (peau d’orange) Does not respond to antibiotics Worse prognosis than other breast cancers

Answer 80

Looks like eczema of the nipple/areolar Erythematous, scaly rash Nipple discharge which may be bloody Burning sensation, increased sensitivity or pain Nipple changes such as nipple retraction or inversion In some cases there may be a palpable breast lump There may be a skin ulcer which does not heal Indicates breast cancer involving the nipple May represent DCIS or invasive breast cancer Requires biopsy, staging and treatment, as with any other invasive breast cancer

Answer 81

Every woman (including transwomen on hormones) and trans men who have breast tissue are invited for screening every 3 years from 50-70 years of age, can self refer every 3 years after 70. A mammogram is taken (x-ray) and will be classed as satisfactory, abnormal or unclear. X rays taken in the caudal-cranial (CC) and mediolateral oblique (MLO) views.

Answer 82

Early detection of cancers Approximately 20% reduction in relative risk of death from breast cancer Can provide peace of mind for some patients

Answer 83

Mammograms are painful and felt to be undignified by some Screening is not 100% sensitive and some cancers are missed (i.e. false negatives) Some research suggests that for every 2000 women screened for 10 years, 1 life is saved and 10 healthy patients are treated unnecessarily False positive results can be emotionally distressing for patients

Answer 84

No there are different recommendations for women with a high genetic/familial risk. The following may be reason to refer for genetic screening: One first degree relative with breast cancer diagnosed before 40 years old Any male first degree relative with breast cancer (any age) One first degree relative with bilateral breast cancer the first of which was diagnosed <50 years old Two first degree, or one first and one second degree relative with breast cancer at any age One first/second degree relative with breast cancer and another first/second degree relative with ovarian cancer (any age) Three first/second degree relatives with breast cancer (any age) If positive then they may be offered annual screening, genetic counselling, chemoprevention or risk reducing surgery

Answer 85

Breast and/or axillary lump (irregular, hard, fixed) Breast pain Breast skin changes (tethering, oedema, Peau d’orange) Nipples changes (Inversion, discharge, especially if bloody, dilated veins) Lymphadenopathy Signs of metastatic disease

Answer 86

An unexplained breast or axillary lump in patients aged 30 or above Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes) Skin changes suggestive of breast cancer The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Answer 87

Triple assessment 1. Clinical examination: of the breast and surrounding lymph nodes 2. Radiological examination: most commonly mammography but can also involve breast ultrasound and MRI 3. Biopsy: typically a core needle biopsy or fine needle aspirate (FNA) If there's suspicion on the imaging then may opt for core needle over fine needle because it gives histology as well as cytology

Answer 88

Younger women generally have more dense breasts with more glandular tissue. Ultrasound scans are typically used to assess lumps in younger women (e.g., under 30 years). They are helpful in distinguishing solid lumps (e.g., fibroadenoma or cancer) from cystic (fluid-filled) lumps. However mammograms are better at picking up on calcifications.

Answer 89

TNM T 0-4 N 0-3 M 0-1

Answer 90

Ultrasound scan and biopsy of axillary lymph nodes Gene expression profiling suggested for women with early breast cancers that are ER positive but HER2 and lymph node negative. Surgical - WLE, Sentinel node biopsy, axillary node clearance, mastectomy, reconstruction Radiotherapy - Almost all patients with WLE will have adjuvant radiotherapy and also mastectomy patients with higher cancer stages (i.e. T3 or 4 or positive nodes) Chemotherapy - can be given to hormone receptor negative and HER2 over-expressing patients and sometimes neoadjuvant chemotherapy given to downstage tumours before surgery.

Answer 91

L – Lungs L – Liver B – Bones B – Brain 2Ls 2 Bs

Answer 92

Massage techniques to manually drain the lymphatic system (manual lymphatic drainage) Compression bandages Specific lymphoedema exercises to improve lymph drainage Weight loss if overweight Good skin care

Answer 93

Tamoxifen = Pro-drug that is metabolised into active compounds (afimoxifene and endoxifen) which are competitive oestrogen receptor antagonists. Current recommendation is 5 years of Tamoxifen therapy following surgical treatment of oestrogen receptor positive breast cancer in premenopausal women.

Answer 94

Letrozole or Anastrozole = aromatase inhibitors which prevent the synthesis of oestrogen. Take this for 5 years following surgical treatment of oestrogen receptor positive breast cancer for postmenopausal women.

Answer 95

Hot flushes Nausea Vaginal bleeding and discharge Weight gain Increased risk of DVT/PE Increased risk of endometrial cancer – the drug is a weak agonist on endometrial tissue Other inadvertent beneficial effects includes reduced risk of cardiovascular disease and osteoporosis.

Answer 96

Hypo-oestrogenism – hot flushes, fatigue, osteoporosis

Answer 97

Transtuzumab (Herceptin) = A monoclonal antibody against the HER2 receptor. Often given weekly with chemotherapy or 3-weekly following surgery.

Answer 98

Cardiac dysfunction – including heart failure Teratogenicity

Answer 99

Fulvestrant (selective oestrogen receptor downregulator) GnRH agonists (e.g., goserelin or leuprorelin) Ovarian surgery

Answer 100

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor Neratinib (Nerlynx) is a tyrosine kinase inhibitor

Answer 101

Yearly mammograms for 5 years, longer if they are younger than the screening age

Answer 102

Implants, lattisimus dorsi flaps, Transverse Rectus Abdominis Flap (TRAM Flap), Deep Inferior Epigastric Perforator Flap (DIEP Flap)

Answer 103

- common benign tumours of stromal/epithelial breast duct tissue. T - small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue. - They are more common in younger women, aged between 20 and 40 years bcos they respond to oestrogen and progesterone and regress after menopause

Answer 104

Painless, smooth, round, well circumscribed, firm, mobile and up to 3cm diameter

Answer 105

not cancerous or associated with an increased risk of developing breast cancer. Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.

Answer 106

Often referred for triple assessment to rule out more sinister pathology. Can be managed conservatively as they will regress after menopause or can be excised.

Answer 107

- Most common benign breast disease - 20-50 year olds - Breast tissue responds to oestrogen and progesterone becoming fibrous and cystic and fluctuate with the menstrual cycle. - Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.

Answer 108

Bilateral “lumpy” breasts – most commonly in upper outer quadrant, mastalgia and symptoms which worsen with the menstrual cycle – normally peaking 1 week before menstruation

Answer 109

Wearing a supportive bra NSAIDs Avoiding caffeine Applying heat to the area Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Answer 110

- benign, individual, fluid-filled lumps - most often between ages 30 and 50, more so in the perimenopausal period. - Can be painful and may fluctuate in size over the menstrual cycle. They're smooth, well-circumscribed, mobile - Need to exclude cancer, with imaging and aspiration or excision. - Aspiration can resolve symptoms in patients with pain. - Having a breast cyst may slightly increase the risk of breast cancer.

Answer 111

- a benign lump caused by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis. May be due to oil cyst. - Painless, firm, irregular, fixed in local structures, skin dimpling or nipple inversion, overlying skin may be inflamed or bruised - Need triple assessment to rule out cancer as it can appear cancerous on imaging - Usually treated conservatively, can spontaneously resolve or be excised

Answer 112

- Benign tumours of adipose tissue that can occur anywhere on the body where there is fat - Typically soft, painless, mobile, do not cause skin changes - They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed if rapidly growing, causing symptomatic compressive symptoms or aesthetic concerns.

Answer 113

- occur in women that are lactating often after stopping breastfeeding. - They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. - Firm, mobile, painless lump, usually beneath the areola. - Benign and usually resolve without any treatment. You can drain them with a needle. Rarely, they can become infected and require antibiotics.

Answer 114

- Common and related to hormonal fluctuations, usually happens 2 weeks before period and settles during - Presents with bilateral and generalised heaviness and aching and possibly other symptoms of PMS such as low mood, bloating, fatigue or headaches

Answer 115

- Non-cyclical breast pain is more common in women aged 40 – 50 years. - More likely to be localised than cyclical breast pain. - Often no cause is found but can be caused by medications (hormonal contraceptive medications), infection (mastitis) or pregnancy - May be originating from chest wall (costochondritis) or skin (shingles or post-herpetic neuralgia)

Answer 116

A breast pain diary can help diagnose cyclical breast pain. Need to exclude cancer (perform a thorough history and examination), infection and pregnancy (perform a pregnancy test)

Answer 117

Mastitis describes inflammation of the breast tissue, both acute or chronic. Usually caused by S. Aureus, but can occasionally be granulomatous.

Answer 118

Lactational mastitis (more common) in 1/3 breastfeeding women; it usually presents during the first 3 months of breastfeeding or during weaning. Presents with cracked nipples and milk stasis (often caused by poor feeding technique), and is more common with the first child Non-lactational mastitis (less common) can also occur, especially in women with other conditions such as duct ectasia, as a peri-ductal mastitis. Tobacco smoking is an important risk factor, causing damage to the sub-areolar duct walls and predisposing to bacterial infection

Answer 119

Breast pain and tenderness (unilateral) Erythema in a focal area of breast tissue Local warmth and inflammation Nipple discharge Systemic e.g. fever, rigors, myalgia, fatigue, nausea and headache May be development of a breast abscess which presents as a fluctuant, tender mass with overlying erythema

Answer 120

- Reassure lactating women that they can continue to breastfeed - Advise on methods to facilitate milk removal e.g. manual expression - Analgesia - Consider a course of oral antibiotics according to local protocol if they do not improve after 12-24 hours. - Those which have developed into a breast abscess may require needle aspiration (or less commonly incision and drainage) - Cessation of breastfeeding using dopamine agonists (such as Cabergoline) can be considered in women with persistent or multiple areas of infection.

Answer 121

Lactational - flucloxacillin or erythromycin/clarithromycin where there is penicillin allergy Non-Lactational - Broad spec e.g. Co-amoxiclav Erythromycin/clarithromycin (macrolides) plus metronidazole (to cover anaerobes)

Answer 122

An important complication of drainage of a non-lactational abscess is the formation of a mammary duct fistula (a communication between the skin and a subareolar breast duct), which, whilst they can be managed surgically with a fistulectomy and antibiotics, can often recur.

Answer 123

Candidal infection of the nipple often happens after a course of antibiotics. This can lead to recurrent mastitis, as it causes cracked skin on the nipple that creates an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant. Sore nipples bilaterally, particularly after feeding Nipple tenderness and itching Cracked, flaky or shiny areola Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash Topical miconazole 2% to the nipple, after each breastfeed Treatment for the baby (e.g., oral miconazole gel or nystatin)

Answer 124

The key feature that suggests a breast abscess is a swollen, fluctuant, tender lump within the breast. Nipple changes, purulent nipple discharge (pus from the nipple), localised pain, tenderness, warmth, erythema (redness), hardening of the skin or breast tissue, swelling Systemic symptoms = muscle aches, fatigue, fever, signs of sepsis (e.g., tachycardia, raised respiratory rate and confusion)

Answer 125

A suspected abscess can be confirmed via an ultrasound scan if there is any doubt regarding the diagnosis. Referral to the on-call surgical team in the hospital for management Antibiotics Drainage (needle aspiration or surgical incision and drainage) Microscopy, culture and sensitivities of the drained fluid

Answer 126

A palpable, peri-areolar breast mass caused by inflammation and dilation of the large breast ducts. It commonly presents with thick yellow, green or brown nipple discharge bilaterally. It may mimic the appearance of cancer on mammography. Occurs most frequently in perimenopausal women. Smoking is a significant risk factor.

Answer 127

Nipple discharge Tenderness or pain Nipple retraction or inversion A breast lump (pressure on the lump may produce nipple discharge) It may be picked up incidentally on a mammogram, leading to further assessment and investigations.

Answer 128

Triple assessment - Microcalcifications are a key finding on a mammogram but not specific to mammary duct ectasia. May show multiple plasma cells on biopsy. Other Ix: Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct Nipple discharge cytology – examining the cells in a sample of the nipple discharge Ductoscopy – inserting a tiny endoscope (camera) into the duct

Answer 129

- Mammary duct ectasia may resolve spontaneously - Not associated with an increased risk of cancer. Management depends on the individual: - Reassurance after excluding cancer may be all that is required - Symptomatic management of mastalgia (supportive bra and warm compresses) - Antibiotics if infection is suspected or present - Surgical excision of the affected duct (microdochectomy) may be required in problematic cases

Answer 130

Radial scar is a benign sclerosing breast lesion which presents as a stellate pattern of central scarring surrounded by proliferating glandular tissue on mammogram.

Answer 131

A warty lesion that grows within one of the ducts in the breast usually growing in the sub-areolar region. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge in a woman in her 40/50s Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

Answer 132

Intraductal papillomas can occur at any age, but most often occur between 35-55 years. - Often asymptomatic, may be picked up incidentally on mammograms or ultrasound. - Nipple discharge (clear or blood-stained) - Tenderness or pain - A palpable lump

Answer 133

- Triple assessment - Ductography = injecting contrast into the abnormal duct and performing mammograms to visualise that duct. The papilloma will be seen as an area that does not fill with contrast (a “filling defect”). Mx = Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy.

Answer 134

Gynaecomastia refers to the enlargement of the glandular breast tissue in males. Male breast enlargement is relatively common, particularly in adolescents and older men (aged over 50 years). It may also be present in newborns due to circulating maternal hormones, resolving as the maternal hormones are cleared.

Answer 135

High prolactin - dopamine antagonists + prolactinoma Idiopathic Drug induced High oestrogen: Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen) Testicular cancer (oestrogen secretion from a Leydig cell tumour) Liver cirrhosis and liver failure Hyperthyroidism Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer Physiological in teens when oestrogen is high Low Testosterone: Testosterone deficiency in older age Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery) Klinefelter syndrome (XXY sex chromosomes) Orchitis (inflammation of the testicles, e.g., infection with mumps) Testicular damage (e.g., secondary to trauma or torsion)

Answer 136

Anabolic steroids (raise oestrogen levels) Antipsychotics (increase prolactin levels) Digoxin (stimulates oestrogen receptors) Spironolactone (inhibits testosterone production and blocks testosterone receptors) Gonadotrophin-releasing hormone (GnRH) agonists (e.g., goserelin used to treat prostate cancer) Opiates (e.g., illicit heroin use) Marijuana Alcohol

Answer 137

Simple gynaecomastia in an otherwise healthy adolescent may be managed with watchful waiting. Unexplained rapid-onset gynaecomastia in a 30 year old male with no apparent cause may require in-depth investigations. Blood tests: Renal profile (U&Es) Liver function tests (LFTs) Thyroid function tests (TFTs) Testosterone Sex hormone-binding globulin (SHBG) Oestrogen Prolactin (hyperprolactinaemia) Luteinising hormone (LH) and follicle-stimulating hormone (FSH) Alpha-fetoprotein and beta-hCG (testicular cancer) Genetic karyotyping (if Klinefelter’s syndrome is suspected) Imaging: Breast ultrasound (may help assess the extent of gynaecomastia) Mammogram (if cancer is suspected) Biopsy (if cancer is suspected) Testicular ultrasound (if cancer is suspected) Chest x-ray (if lung cancer is suspected)

Answer 138

Treta cause Treatment options in problematic cases (e.g., pain or psychological distress) include: Tamoxifen (a selective oestrogen receptor modulator that reduces the effect of oestrogen on the breast tissue) Surgery

Answer 139

Galactorrhoea refers to breast milk production not associated with pregnancy or breastfeeding.

Answer 140

Idiopathic (no cause can be found) Prolactinomas (hormone-secreting pituitary tumours) Endocrine disorders, particularly hypothyroidism and polycystic ovarian syndrome Medications, particularly dopamine antagonists (i.e., antipsychotic medications)

Answer 141

A pregnancy test in women of childbearing age Bloods: Serum prolactin Renal profile (U&Es) Liver function tests (LFTs) Thyroid function tests (TFTs) MRI for pituitary tumours

Answer 142

Treat underlying cause Dopamine agonists (e.g., bromocriptine or cabergoline) block prolactin secretion and improve symptoms. Trans-sphenoidal surgical removal of the pituitary tumour is the definitive treatment of prolactinoma.