repro 3 Flashcards
triad of PET?
Hypertension
Proteinuria
Oedema
chronic HTN vs PET?
PET after 20 weeks gestation
HTN <20 weeks gestation
eclampsia?
Eclampsia is when seizures occur as a result of pre-eclampsia
high risk factors vs moderate risk factors PET?
High risk factors PET
- Pre-existing hypertension
- Previous hypertension in pregnancy
- Existing autoimmune conditions e.g. SLE
- Diabetes
- CKD
Moderate risk factors PET
- >40 y/o
- BMI >35
- More than 10 years since previous pregnancy
- Multiple pregnancy
- First pregnancy
- FHx of pre-eclampsia
Women are offered aspirin from 12 weeks until birth if they have one high risk factor or more than one moderate risk factor
symptoms pre-eclampsia?
Headache
Visual disturbance/blurriness
Nausea + vomiting
Upper abdominal or epigastric pain (this is due to liver swelling)
Oedema
Reduced urine output
Brisk reflexes
Dx PET?
Systolic BP >140mmHg
Diastolic BP >90mmHg
Plus any of:
- Proteinuria ≥1+ on dipstick
- Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia, or haemolytic anaemia)
- Placental dysfunction (e.g. FGR or abnormal doppler studies)
Tx gestational hypertension without proteinuria?
Aim for BP <135/85mmHg
Admission for women with BP >160/110mmHg
Urine dipstick testing at least weekly
Monitoring of blood tests weekly (FBC, liver enzymes and renal profile)
Monitoring foetal growth by serial growth scans
PlGF testing on one occasion
Tx PET?
Labetolol = 1st line
Nifedipine is 2nd line (1st line in asthma)
Methyldopa 3rd line (needs to be stopped within 2 days of birth)
IV hydralazine used in critical care in severe pre-eclampsia or eclampsia
IV MgSO4 given during seizures, labour and in the 24 hours after labour to prevent seizures
Fluid restriction used during labour in severe pre-eclampsia or eclampsia to avoid fluid overload
Tx PET after birth of baby?
Enalapril (1st line)
Nifedipine or amlodipine (1st line in black African or Caribbean patients)
Labetolol (3rd line)
Tx eclampsia?
Seizures associated with pre-eclampsia
Tx = IV MgSO4
HELLP syndrome?
Complication of pre-eclampsia and eclampsia
- Haemolysis
- Elevated Liver enzymes
- Low Platelets
where does breast lie?
sits anterior to pectoralis major
secretory tissue of breast made up of?
Secretory tissue of breast made up of 15-25 lobes
Each lobe consists of tubulo-acinar gland which drains via a series of ducts leading to the nipple
Adjacent to secretory lobules is dense fibrous tissue which is surrounded by adipose tissue
….
basic functional secretory unit of breast?
TDLU - terminal duct lobular unit
drainage of secretions from breast?
In non-lactating breast, TDLUs lead into intralobular collecting duct → lactiferous duct → nipple
(expanded duct region near nipple = lactiferous sinus)
which cells line acini in lobule?
cuboidal/columnar = secretory epithelium
lactiferous duct lined by?
as lactiferous ducts approach surface they become lined by stratified squamous epithelium
Deeper they are lined by stratified cuboidal epithelium
changes in breast during menstrual cycle?
Luteal phase
- epithelial cells increase in height
- Lamina of ducts become enlarged
- Small amounts of secretions appear in ducts
changes to breast in pregnancy?
First trimester - elongation and branching of smaller ducts
- Also proliferation of epithelial cells, glands + myoepithelial cells
Second trimester - glandular tissue continues to develop
- Secretory alveoli differentiate
- Plasma cells and lymphocytes infiltrate tissue
Third trimester
- Secretory alveoli continue to mature with development of extensive rER
(these changes are accompanied by reduction in amount of connective + adipose tissue)
which hormones stimulate proliferation of breast secretory tissue in pregnancy?
oestrogen + progesterone
composition of human milk
88% water
1.5% protein (lactalbumin and casein)
7% carbohydrate (lactose)
3.5% lipid
Small quantities of ions, vitamins + IgA
mechanisms of milk secretion?
2 mechanisms!
Lipid droplets = apocrine secretion
- Droplets secreted carrying small amount of cytoplasm with it
Proteins = merocrine secretion (also called exocytosis)
- Proteins in milk made in rER
- Secreted via vesicles which merge with apical membrane to release only their contents into duct system
changes to breast after menopause?
Secretory cells in TDLU degenerate leaving only ducts
In connective tissue, fewer fibroblasts and reduced collagen and elastic fibres
blood supply/drainage to breast
lymph drainage of breast
diagnostic Ix breast lump?
Needle core biopsy
Vacuum assisted (large volume) biopsy
Skin biopsy
Incisional biopsy of mass
therapeutic approaches breast cancer?
Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer
- Wide local excision
- Mastectomy
needle core biopsy results?
B1 - unsatisfactory/normal (doesn’t rule out malignancy?)
B2 - benign
B3 - atypia, probably benign
B4 - suspicious of malignancy
B5 - malignant
- B5a - CIS
- B5b - invasive
which cell types line ducts + lobules?
Myoepithelial cells - CONTRACTILE
- Assist in milk ejection + provide structural support to lobules
Epithelial cells
- Produce milk
both lie on basement membrane
benign breast tumours?
Phyllodes tumour
Intraductal papilloma
Ax gynaecomastia male?
exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease (metabolises oestrogen)
fibrocystic change affects?
risk factors?
Symptoms?
Macroscopic features?
Miscroscopic features?
Tx?
very common in women age 20-50
RF = early menarche or late menopause
symptoms = smooth discrete lumps, sudden pain, cyclical pain, or asymptomatic
macroscopic = usualy small + multiple
microscopic = apocrine metaplasia (change of ductal depithelium to apocrine)
Tx = exclude malignancy
- reassure (most resolve after menopause)
- excise if necessary
hamartoma?
Circumscribed lesion composed of cell types normal to breast but in excess
fibroadenoma?
risk factors?
clinical features?
histological features?
Common - peak incidence in 30s
RF = commoner in african women
Clinical features
- Usually solitary
- Painless, firm, mobile, discrete
- “Breast mouse” because of how mobile they are
- Solid on USS
biphasic tumour = epithelium + stroma
Tx fibroadenoma?
Reassure
Excise if patient wishes
sclerosing lesions breast?
malignant?
Sclerosing adenosis and radial scar
benign but may mimic carcinoma! - esp radial scar
sclerosing adenosis s/s?
often asymptoamtic but can present with pain, tenderness, lumpiness/thickening
radial scar features?
<10mm
stellate shape
central puckering
radiating fibrosis
Dx radial scar?
requires vacuum biopsy as can mimic + become carcinoma
fat necrosis Ax?
features?
Tx?
local trauma (seat belt injury) + Warfarin
features = foamy macrophages + fibrosis
Tx = exclude malignancy + reassure
duct ectasia?
clinical features?
risk factors?
Tx?
affects subareolar ducts
clinical features
- pain
- acute episodic inflammatory changes
- bloody or purulent discharge
- nipple retraction
associated wih smoking!!
Tx = treat acute infections, exclude malignancy, stop smoking, excise ducts
Ax acute mastitis/abscess?
Tx?
Ax = 2 main causes
- duct ectasia (mixed organisms + anaerobes)
- lacation (staph aureus)
Tx = antibiotics, percutaneous drainage if abscess
- treat underlying cause i.e. remove ectasia
phyllodes tumour affects?
features?
Tx?
Age 40-50
features
- Slow-growing unilateral mass
- Biphasic tumour - unlike fibroadenoma, dominated by stromal overgrowth
- leaf-like structure
Tx = prone to local recurrence if not adequetely excised
intraductal papilloma s/s?
Tx?
Nipple discharge +/- blood
large lump near nipple + smaller lumps further from nipple
Treatment
- Benign can be excised without margins
- However, atypia or CIS needs completely excised with margins
malignant tumours breast?
Malignant phyllodes tumour
Angiosarcoma - post radiotherapy (iatrogenic)
Lymphoma
Metastatic tumours
- Carcinoma: lung, ovarian, clear cell of kidney
- Melanoma
- Soft tissue tumours - leiomyosarcoma
- You can get primary leiomyosarcoma of the breast, precursor is phyllodes
breast carcinoma refers to?
Specifically talking about epithelial cells
- Glandular epithelium of TDLU
It is an adenocarcinoma but usually just referred to as breast carcinoma
precursor lesions breast carcinoma?
Ductal
- Epithelial hyperplasia
- Columnar cell change +/- atypia
- Atypical ductal hyperplasia
- Ductal carcinoma in situ
Lobular
- Lobular in situ neoplasia
- Atypical lobular hyperplasia
- Lobular carcinoma in situ
in situ carcinoma?
Confined within basement membrane
Malignant but non-invasive
Precursors of invasive carcinoma
Classification
- Lobular
- Ductal
lobular in situ carcinoma types?
features?
Tx?
2 types
- Atypical lobular hyperplasia (<50% of lobule involved)
- Lobular carcinoma in situ (>50% lobule involved)
features:
- multifocal and bilateral
- Incidence decreases after menopause
- Not palpable, not visible grossly
- May calcify - mammography
Tx = ????? excision not possible because multifocal and bilateral - so mastectomy??? since true precursor for carcinoma
ductal carcinoma in situ (DCIS) features?
15-20% of breast malignancies are DCIS
Arise in TDLU
Single duct
malignant epithelial cells confined within basement membrane
May involve nipple skin (Paget’s)
Paget’s disease of nipple?
S/s?
High grade DCIS extending along ducts to reach epidermis of nipple
Still in situ carcinoma!!!!
s/s = itchy, sore, discoloured, ulcerated
DCIS risk?
Tx?
75% progress to carcinoma
Tx
- surgery
- radiotherapy (don’t use chemo)
microinvasive carcinoma?
Rare
DCIS (high grade) with invasion <1mm
Treat as DCIS rather than carcinoma in terms of management
risk factors breast cancer?
protective factors?
- risk increases with age
- COCP, HRT
- early menarche, late menopause
- nulliparous
- precursor lesions
- BMI, alcohol, smoking
- genetics
- 1st degree relative doubles risk
- BRCA1, BRCA2, TP53, PTEN
exercise + NSAIDs lower risk
mortality of breast cancer?
commonest type of breast carcinoma?
ductal carcinoma
breast carcinoma grading?
Objective assessment of
- Tubular differentiation (1-3)
- Nuclear pleomorphism (1-3)
- Mitotic activity (1-3)
So total scores
- 3, 4 or 5 = grade 1
- 6 or 7 = grade 2
- 8 or 9 = grade 3
hormone receptors breast cancer?
Tx?
80% oestrogen receptor (ER) positive
- anti-oestrogen therapy
- oophrectomy
- tamoxifen
- aromatase inhibitors (letrozole)
- GnRH antagonists (goserelin)
Progesterone receptor
HER2
- Tx = trastuzumab (herceptin)
tumour staging breast cancer
presentation breast cancer?
50% asymptomatic
50% symptomatic:
- dimpled skin
- visible lump
- nipple change e.g. inversion
- bloody discharge
- texture change (peu d’orange)
- colour change
process breast clinic?
examination + mammogram + USS
treatment breast cancer?
Local (surgery, radiotherapy)
General (chemo, hormonal therapies, targeted therapies)
- Small tumours = lumpectomy
- Large tumours = mastectomy
systemic Tx breast cancer?
Chemo
- Adjuvant
- Neo-adjuvant
Hormonal therapy
- Non-invasive (SERMs, AIs, GnRH)
- Invasive (oophorectomy)
Targeted therapies
- Trastuzumab (herceptin)
nipple discharge that isn’t blood or yellow?
physiological
mammogram vs USS for breast lumps?
Mammogram only useful >40 age
USS before that
if size of lump fluctuates with mensrual cycle?
likely to be benign
eczema of the nipple?
paget’s disease
tomosynthesis?
3D mammography
imaging modality of choice for women with palpable mass?
USS
disadvantages USS?
low sensitivity DCIS (mammogram has high sensitivity)
uses of MRI in breast disease?
lobular cancer
Paget’s disease of nipple
commonest cause of breast lump age <30?
30-50?
>50?
<30 = fibroadenoma
30-50 = cyst
>50 = cancer
Best imaging modality to assess breast masses?
then?
USS
then do mammorgaphy if US findings suspicious or age >40
cyst
cancer - irregular, taller than it is wide (fibroadenomas wider than they are tall)
staging of advanced or recurrent breast cancer?
CT chest, abdomen, pelvis to look for metastasis
(not required in local operable breast cancer)
worrying nipple discharge?
Ax?
unilateral single duct is worrying
Ax
- Invasive cancer
- DCIS
- Duct ectasia
- Papilloma
breast asbcess/infection seen in?
Tend to see in 2 groups of patients
- Breast feeding
- Duct ectasia - smokers
types of breast surgery for cancer?
breast conservation (just as effective)
mastectomy
procedure breast conservation?
clear margins >1mm PLUS
breast radiotherapy
axillary metastasis staging?
axillary treatment options?
complications?
USS axilla + core biopsy
axillary Tx = axillary clearance + radiotherapy
comps = axillary node clearance can result in lymphoedema
neoadjuvant endocrine therapy?
pre or peri-menopausal (menstruation in last year)
- tamoxifen 20mg daily for 12 months + goserelin implant
- letrozole 2.5mg daily for 12 months + goserelin implant
post-menopausal
- letrozole 2.5mg daily for 12 months
side effects aromatase inhibitors?
joint pain
fatigue
weight gain
loss of libido
mood swings
mammogram + biopsy
Dx?
next step?
Tx?
sentinel node biopsy indicated?
Dx = suggestive of DCIS
vacuum biopsy
Tx = surgery + radiotherapy (no chemo)
no its DCIS so in-situ i.e. cant metastasise
Dx?
next steps?
Tx?
Dx = cancer or radial scar
next steps = core biopsy (no need for vacuum as localised mass)
Tx = WLE
Tx = neoadjuvant chemo - trastuzumab
then WLE + axillary node clearance
