Neoplasms + Disorders of the Breast Flashcards
Risk factors for breast cancer
- Menarche before age 12
- Old age of first full-term pregnancy, no pregnancies
- Menopause after age 52
- Breast mass- immobile, irregular
- Nipple retraction, bloody nipple discharge
MC type of breast cancer
Infiltrating Intraductal Carcinoma (IIC) 80%
- Infiltrating lobular (10%) frequently bilateral
- Paget’s disease of the nipple (1%) chronic eczematous itchy, scaling rash on the nipples and areola
- Inflammatory breast cancer (2%) red swollen, warm and itchy breast often with nipple retraction and peau d’orange (NO LUMP)
When should mammo’s begin?
every 2 years from age 50-74
Every 2 years beginning at age 40 if increased risk factors – 10 years prior to the age the 1’st degree relative was diagnosed.
- Clinical breast exam every 3 years in women age 20-39 years then annually after age 40
- Breast self-exam monthly beginning at age 20 – immediately after menstruation on days 5-7 of the menstrual cycle
Tx of breast cancer
- Segmental mastectomy (lumpectomy) followed by breast irradiation in all patients and adjunctive chemotherapy in women with positive nodes stage I and stage II with tumors less than 4 cm in diameter
- Anti-estrogen Tamoxifen is useful in tumors that are ER-positive – binds and blocks the estrogen receptor in the breast tissue
- Aromatase inhibitors are useful in postmenopausal ER-positive patients with breast cancer – reduces the production of estrogen
- Monoclonal AB treatment is useful in patients with HER2 positivity (Human Epidermal Growth Factor Receptor)
What clinical triad is strongly indicative of cervical cancer extension to the pelvic wall?
Unilateral leg edema, sciatic pain, ureteral obstruction
abnormal vaginal bleeding, most commonly postmenopausal
80% present with these sx = Cervical cancer
MC type of cervical cancer
- 80% are squamous cells and arise from the squamocolumnar junction of the cervix (transformational zone)
- HPV is 99% of the reason for cervical cancer, types that cause cancer are 16,18,31 and 33. Especially types 16, 18
- Associated with cigarette smoking
RF of cervical cancer
Multiple sexual partners, early age at first intercourse, early first pregnancy, and HPV positive
Dx of cervical cancer
Friable, bleeding cervical lesion on exam
- Biopsy of gross lesions and colposcopically directed biopsies are the definitive means of diagnosis
- Majority of cases (80%) are invasive squamous cell types usually arising from the ectocervix
Tx of cervical cancer
Resect and/or chemotherapy and radiation
- Stage 1: conservative, simple, or radical hysterectomy
- Stage 2 +: chemo +/– radiation
- 5-y survival– Stage 1: 85%-90% Stage 2: 65% Stage 3: 29% Stage 4: 21%
At what age should your patient receive their first PAP regardless of sexual activity?
First PAP at the age of 21 regardless of sexual activity (no pap indicated prior to that)
For women aged 21 to 29, all guidelines recommend only cytology screening every
3 years
For women 30 years and older, combination of cytology + HPV testing is recommended every
Every 5 years
Who should get annual cervical screenings?
- Annual screening is recommended for any high-risk groups (HIV infection, immunosuppression, or in utero DES exposure) or women who have treated in the past for CIN 2, CIN 3, or cervical cancer
What are the ACOG recommendations for discontinuing papsmear
- No cytology screening after total hysterectomy if surgery for benign condition. If surgery for CIN I, II, or III, then annually three times before discontinuing.
- Discontinue screening at age 65 for women who have had adequate recent screening. Adequate screening is defined as three consecutive negative cytology tests or two consecutive negative HPV/Pap co-tests in the 10 years before stopping, with the most recent test within 5 years
What are the PAP screening pathology report findings:
- ASC-US: Atypical squamous cells of undetermined significance
- LSIL: Low-grade squamous intraepithelial lesion, that is, mild dysplasia, CIN I
- HSIL: High-grade squamous intraepithelial lesion, that is, moderate to severe dysplasia, CIN II-III, carcinoma in situ
Which types of HPV have a high likelihood of leading to cervical cancer
HPV types 16, 18, and 31 are risk factors for cervical dysplasia, which can lead to cervical cancer
Women with negative cytology and HPV positive ⇒ both tests should be repeated in
12 months
Tx of ASC-US or LSIL, CIN-1
- Reflex HPV
-
If positive and at least 25 years old – colposcopy
- If negative or under 25 years old – retest in 1 year
-
If positive and at least 25 years old – colposcopy
Tx of HSIL, CIN-2, CIN-3, CIS
- Colposcopy
- Outside cervix – LEEP or cryotherapy
- Inside cervix – cone biopsy
- Squamous cell carcinoma ⇒ Resect and/or chemotherapy and radiation
When is the HPV vaccine recommended?
- Females and males – HPV vaccine is recommended at 11 to 12 years. It can be administered starting at 9 years of age, and catch-up vaccination is recommended for females aged 13 to 26 years who have not been previously vaccinated or who have not completed the vaccine series.
Can pregnant women receive the HPV vaccine?
Not recommended
males 22 to 26 years old, catch-up HPV vaccination is recommended if they are
men who have sex with men or immunocompromised (including HIV-infected males).
What is the dosing for the HPV vaccine if <15 yo
- < 15 years old: administer a two- rather than a three-dose vaccine series. In such patients, the two doses are administered at least six months apart
> 15 years old: the HPV vaccine is administered in
three doses at 0, at 1 to 2 months, and at 6 months
Immunocompromised should also have 3 dose vaccine series
most common GYN malignancy and the fourth most common malignancy in women in the US
Endometrial cancer
postmenopausal vaginal bleeding ⇒ One-third of women with postmenopausal bleeding have
Endometrial cancer
MC type of endometrial cancer
Adenocarcinoma
Risk factors for endometrial cancer
Obesity, nulliparity, early menarche, late menopause, unopposed estrogen stimulation, hypertension, gallbladder disease, DM, prior ovarian, endometrial, or breast cancer
Dx of endometrial cancer
Endometrial biopsy is the gold standard definitive diagnostic test
Endometrial biopsy is indicated in all postmenopausal women vaginal bleeding
Tx of endometrial cancer
total hysterectomy and bilateral salpingo-oophorectomy, pelvic radiation therapy with or without chemotherapy for stage II or III cancer
second most common type of GYN cancerin women (the first is endometrial cancer)
Ovarian cancer
40-60 years of age, ascites, abdominal pain ⇒ 75% diagnosed at an advanced stage
Ovarian cancer
What are protective factors and risk factors for ovarian cancer?
-
Protective factors for the risk of ovarian cancer include multiparty, OCP use, and breast-feeding
- Use of oral contraceptives: 5 years of use decreases risk by 20%; 15 years by 50%
- Risk factors: nulligravidity (or infertility), early menarche, late menopause, endometriosis
- 90% are epithelial tumors ⇒ germ cell tumors are more common in patients < 10 years old
Dx of ovarian cancer
Diagnose with transvaginal ultrasound then biopsy
- Serum tumor marker CA-125 ⇒ BRCA1 gene is associated with 5% of cases
Tx of ovarian cancer
Stage 1A or 1B—Surgical excision alone (abdominal hysterectomy and bilateral salpingo-oophorectomy)
- Other stages—Surgical resection followed by adjuvant chemotherapy or radiation
- Monitor CA-125 afterward to assess disease progress
What are the known risk factors for vulvar/vaginal carcinoma?
HPV infection, Smoking, Coexisting cervical carcinoma, In utero exposure to DES
MC type of vaginal/vulvar neoplasms
Squamous cell represents 95% caused by HPV
- Adenocarcinoma caused by DES exposure
MC location of vaginal/vulvar neoplasms
- Most common location of vaginal carcinoma is the upper one-third of the posterior vaginal wall
Sx and Tx of vaginal/vulvar neoplasms
Usually presents as changes in menstrual period and/or abnormal vaginal bleeding
TX: with radiation therapy
- Vaginal pruritus is the most common presentation (70% will present with this symptom) of this type of cancer
Vulvar cancer
MCC of vulvar cancer
- 90% are squamous cell cancers and melanoma. Risks include HPV subtypes 16, 18, and 31 – pruritic black lesions`
Tx of vulvar cancer
Vulvectomy and lymph node dissection
Paget’s – pruritic red lesions
TX: Local resection
Dx of vulvar cancer
Application of acetic acid or staining with toluidine blue may help direct optimal biopsy location
32-year-old lactating female with breast pain, swelling, fever, chills, and a fluctuant mass of her left breast. The area directly above the lesion is warm, erythematous and tender to touch.
Breast abscess
Should a patient with a breast abscess continue to breastfeed on the affected side?
Women should be encouraged to continue breastfeeding following breast infection, even in the setting of incision and drainage
MCC of breast abscess
Staphylococcus aureus is the most common cause
A progression from mastitis - symptoms are the same with the addition of localized mass and systemic signs of infection
Tx of breast abscess
I&D and anti-staph antibiotics
- Regimen: Nafcillin/oxacillin IV or cefazolin PLUS metronidazole
- Alternative is Vancomycin
- Women should be encouraged to continue breastfeeding following breast infection, even in the setting of incision and drainage
a 27-year-old female with a painless mass in the left breast. She discovered this mass three months ago while showering and reports it has been unchanged since that time. Her last menstrual period was 10 days ago. There is no family history of breast cancer. On physical exam, you palpate a 3 cm, firm, non-tender mass in the upper lateral quadrant of the left breast. The mass is smooth, well-circumscribed, and mobile. There are no skin changes, nipple discharge, or axillary lymphadenopathy
Breast fibroadenoma
Most common type of noncancerous breast tumor that most often occurs in young women
Breast fibroadenoma
Sx of breast fibroadenoma
- small, firm, usually painless, well-circumscribed, completely round, and freely mobile breast mass
- The classic description with respect to consistency is “rubbery.”
Dx of breast fibroadenoma
Diagnostic mammogram with ultrasound
- If indeterminant, fine-needle aspiration of the mass with pathology
- In women younger than 25 years, fibroadenomatous mass should be biopsied
Tx of breast fibroadenoma
After the establishment of fibrocystic breast disease recommended treatments include:
- Avoiding trauma and by wearing a bra with adequate support
- Combined oral contraceptive agents limit the severity of the cyclical changes in the breast tissue
- Many patients report relief of symptoms after abstinence from coffee, tea, and chocolate
42-year-old woman with breast masses that changes in size, especially during her menstrual cycles. These masses are usually painful and pain radiates into the axillae. She reports that her breasts often feel full and heavy. Occasionally she has a small amount of greenish-brown nipple discharge. An ultrasound exam shows cystic masses within the breasts
Fibrocystic breast disease
benign (noncancerous) condition in which the breasts feel lumpy
Fibrocystic breast disease
Dx of fibrocystic breast dz
Diagnosis is by breast cyst aspiration supplemented by ultrasound and/or mammogram
- Straw-colored fluid with no blood
Tx of fibrocystic breast dz
Treat with NSAIDs, heat or ice, support bra, decrease caffeine, fat chocolate
- Women should be encouraged to perform monthly self-breast exams one week after period when cysts are at their smallest
- Oral contraceptives with low estrogenic activity and potent progestin, medroxyprogesterone acetate
- Most resolve spontaneously ⇒ +/- fine needle aspiration for removal of fluid
Patient with infectious mastitis present as → a breastfeeding woman 3 weeks postpartum complaining of a painful area of the breast that is reddened and warm. The patient feels very fatigued with a fever generally > 101 ° F and chills. She reports a burning pain present constantly or at times only while breastfeeding. On exam, the patient appears ill. Breast examination shows an erythematous right breast with a palpable mass, induration, erythema, and tenderness to palpation.
Mastitis
What is the most common causative organism in mastitis, breast infection, or breast abscess?
Staph aureus
A regional infection of the breast from skin flora or oral flora of breastfeeding baby – organisms enter erosion or cracked nipple; the main cause is clogged milk ducts
Mastitis
Sx of mastitis
- Unilateral erythema, tenderness, usually only one quadrant of the breast affected, fever and chills
- Congestive (bilateral) vs. Infectious (unilateral)
- Usually caused by S.aureus
Dx of mastitis
Clinical - if an abscess is suspected and ultrasound may be warranted
Tx of mastitis
warm compresses to the breast and analgesics
- If infectious, treat with dicloxacillin, cephalexin or erythromycin for staphylococcus aureus alternate is clindamycin
- Continue to breastfeed on the affected side along with warm heat 4 times per day
