reproductive Flashcards
aetiology of torsion of testis
- Children/young adults – commonest in neonatal period and around puberty
- Undescended testis
clinical features of torsion of testis
- Sudden onset severe painful testis – triggered by activity e.g. playing sports
- Vomiting
- Abdo pain
- Testicular exam: Red, tender, firm, swollen testis
- Opposite testis may lie horizontally (Angell’s sign)
- Abnormal rotation so that epididymis is not in posterior position
- Elevated (retracted) testicle
- Bell clapper deformity: absence of fixation of the tesicle posteriorly to the tunica vaginalis
- Lack of cremasteric reflex: testicle will not contract if torsion is present
- Prehn’s sign – worse pain when elevation of the testicles
investigation for torsion of testis
doppler USS - only if in double, otherwise straight to surgery
urine dip to check not infeective
differentials to testis torsion
epididymitis - pain relieved when lifted
epididymo-orchitis hydrocele/varicocele - shine light testicular cancer inguinal hernia renal colic HSP acute appendicitis
management of torsion of testis?
immediate referal to surgery - 6 our windwo before ischaemia is irrevesible
- surgical scrotal exploration
- untwisting of the testicle and orchiplexy (fixing both testicles to preventing further episodes)
- orchiectomy if necrosis
aetiology of ectopic pregnancy
PIPPA
- previous ectopic
- intrauterine contraceptive device
- PID
- pelvic/tubal surgery
- assisted reproduction
clinical features of ectopic pregnancy
presents around 6-8 weeks
usually a history of amenorrhoea (for around 8 weeks)/known to be pregnany
lower abdo pain - constant, iliac fossa
lower abdominal /cervical/adnexal tenderness
PV bleeding
breast tenderness
urinary symptoms
rectal pressure/pain on deification
clinical features of a ruptured ectopic pregnancy
collpase/fainting diarrhoea vomiting pain in the shoulder - haemorrhagic blood irritates the diaphragm shock Cullen's sign
investigation for ectopic pregnancy
pregnancy test - +Ve
TV USS - establish the location of the pregnancy, the presence of adnexal massess or freee fluid
serum hCG at 0 and 48 hour
- a rise > 63% suggests intrauterine pregnancy
- a suboptimal rise is suspicious of an ectopic pregnancy
- decrease of > 50% = likely failing pregnancy
management of rupture of ectopic pregnancy
resuss A-E assessment
followed by salpingectomy
when will you use expectant management of ectopic pregnancy
- stable
- asymptomatic
- hCG < 1500 iU
• EP <3cm and no fetal cardiac activity on TV USS
• No haemoperitoneum on TV USS
• Fully understand symptoms and implications of EP.
• Language should not be a barrier to understanding or communicating the problem to a third party (e.g. ambulance).
• Live in close proximity to the hospital and have support at home.
• You deem the patient will not default on follow up.
• Requires serum hCG initially every 48 hours until repeated fall in level, then weekly until <15IU.
when will you use medical management of ectopic pregnancy
failed expectant management
Methotrexate is given IM as a single dose of 50mg/m2.
• Criteria:
• Follow up possible
• Unruptured
• Adnexal mass <35mm
• No visible heart beat
• No significant pain
• hCG level <1500 IU/l
• Confirmed absence of intrauterine pregnancy on USS
• hCG levels should be measured at 4 and 7 days and another dose of methotrexate given (up to 25% of cases) if the in hCG is <15% on days 4-7
• Sexual intercourse should be avoided during treatment and reliable contraception used for 3 months after as meth
otrexate is teratogenic.
when will you use surgical management of ectopic pregnancy
when medical management fails
laparoscopy salpingectomy if - hemodynamically unstable - unable to return for follow up - significant pain - adnexal mass > 35 mm - foetal heartbeat visible on USS - hcg level > 5000 give methotrexate post-surgery
what is another name for genital wart
condylomata acuminate
aetiology of genital warts
Human Papilloma virus - subtype 6 and 11
early onset sexual activity
inc number of sexual patner
lack of barrier contraception
how is genital wart transmitted?
most often via sexual contact
incubation period between 3 weeks and 8 months
clinical features of genital warts
appearance varies
- tiny flat patches on vulval skin
- small papiliform (cauliflower-like) wellings
- may affect the cervix
many asymptomatic
localized skin irritation
implications in pregnancy
- tend to grow rapidly
- usually regress after delivery
Ix for genital warts
clinical diagnosis
a biopsy might be taken to exclude neoplasia
differential for genital wart
syphilius
molluscum contagiosum
pearly penile papules
skin tags
management of genital warts
- can just leave it if pt wishes
- podophyllotoxin applied locally
- or trichloroacetic acid for non keratinized lesions
- or imiquimod (for both keratinized and non-keratinized warts)
- cryotherapy or excision or electrosurgery or laser treatment
partner notification is not necessary
what is molluscum contagiosum
Sexual transmission usually affecting young adults. Affects genitals, pubic region, lower abdomen, upper thighs, and/or buttocks
characteristic of molluscum contagiosum
Lesions are usually characteristic, presenting as smooth-surfaced, firm, dome-shaped papules with central umbilication
treatment of molluscum contagiosum
no treatment
investigation for molluscum contagiosum
clinical, on the basis of recognising the characteristic lesions
offer a routine STI screen
how long is the incubation period of genital herpes
2-12 days
spread by skin to skin contact
which herpes subtype causes genital herpes lesions
HSV-2
which herpes subtype causes oral herpes lesions
HSV-1
pathophysiology of genital herpes
HSV-2 spread via skin to skin spread
HSV-2 then infect the host local tissue, it then ascends via the sensory neuron to the sensory ganglion where it remain din latent state
the virus might then periodically reactivates, traveling down the axon and into the basal skin layers
clinical features of primary genital herpes
usually the most severe and often result in
- flu-like illness (muscle aches, malaise, headache)
- women - fever, neuralgia, dysuria, constipation
- discharge
- inguinal lymphadenopathy
- vulvitis and pain
- if no pain - consider syphilis
- small, characteristic vesicles and ulcers on the vulva (painful/tingling) - painful enough to cause urinary retention –> progress to ulceration –> crusted lesion
- typcially lasts around 3 weeks
clinical features of secondary genital herpes
recurrent attacks result from reactivation of latent virus in the sacral ganglia - usually short and less severe - lesions and pain
- can be triggered by stress, sex, menstruation
investigation for genital herpes
clinical and history
viral PCR of versicle fluid = gold standard
management of genital herpes
- Reassure patient that recurrences are mild and short lived- saline baths and topical anaesthetic gels/creams/ice packs may help self-management
- Abstain from sexual intercourse until follow up/lesions have cleared
- Treatment with oral acyclovir may be effective if given within 5 days of onset of symptoms
in pregnancy
- if labour is within 6 weeks of primary infection then delivery by CS
complications of genital herpes
meningitis sacral radiclopathy transverse myelitis disseminated infection myalgia fulminant hepatitis pneumonia
Implications in pregnancy:
• Miscarriage
• Preterm labour.
• Neonatal risks:
• Transmission rate from vaginal delivery during primary maternal infection may be as high as 50% but is relatively uncommon during a recurrent attack (<5%).
• Neonatal herpes appears during the first two weeks of life
what is the advise for those who is HIV +ve but want to conceive
- Adviced to wait till viral load is low to conceive
- Mother = self-insemination
- Father = washing of sperm/donor
- Continue HAART OR start at between 14-24 weeks if not already on
what intervention will need to be taken in the delivery phase of a HIV mother
- ↑ risk of transmission if:
- <34 weeks
- PROM
- Invasive procedure conducted e.g. fetal blood sample
inc viral load (> 10000)/take zodovudine alone = C-section within 4 hours of SROM + IV infusion of zidovudine
otherwise vaginal delivery with IV infusion of zidovudine as soon as SROM occurs
what is the treatment of the newborn baby from a HIV +ve mother?
ART for 3-6 weeks
HIV DNA PCR necessary
- less than 48 hour after birth
- prior to discharge
- @ 6 weeks, 12 weeks, 18 weeks..
what causes gonorrhea
gram -ve diplococcus Neisseria gonorrhoeae
how long is the incubation period of gonorrhoea
2 to 5 days
clinical features of gonorrhoea
sometimes asymptomatic
female - greenish vaginal discharge, 2-7 days after intercourse - mucopurulent discharge - dysuria - IMB/PCB abdo pain
Male - discharge - yellow, green, white - dysuria - urethritis conjunctivitis - swelling of the foreskin - scrotal pain/swelling - testicular pain - tender inguinal lymph nodes - infection of rectum, throat and eyes - rectal pain and discharge
investigation of gonorrhoea
women
- VVS for NAAT testing
- swab for culture and sensitivity
men
- urien for NAAT testing
- rectal swabs and pharyngeal swabs if MSM
management of gonorrhoea
ceftriaxone 500mg IM stat as a single dose
test of cure 3 weeks after completion of course of antibiotics
complications of gonorrhea
PID dyspareunia epididymo-orchitis vulvo-vaginitis prostatitis tubal infertility
what is paraphimosis
foreskin of uncircumcised penis is retracted and left behind the glans penis leading to vascular engorgement and oedema of the distal glans medical emergency
aetiology of paraphimosis
- Age 2-6 = normal physiology
- Most common foreskin left retracted by healthcare professionals after examining, catheterisaton or cystoscopy
- Injury
- Balanitis
- STIs
- Diabetes
- Eczema
- Psoriasis
- Lichen planus
- Lichen sclerosis
clinical features of paraphimosis
- Penile pain
- Band of retracted foreskin tissue beneath the glans
- Swollen glans penis
- Redness of penis
ix of paraphimosis
clinical diagnosis
management of paraphimosis
Acute
With ischemia/necrosis = emergency debridement OTHERWISE
1) Manual manipulation – LA and compression until swelling improved
2) Puncture technique (perforation of the foreskin at multiple locations)
3) Surgical reduction + circumcision
Chronic
1) Surgical reduction + circumcision
complication of paraphimosis
necrosis of the glans/foreskin
pathophysiology of phimosis
foreskin is unable to be retracted
• The inner foreskin is attached to the glans
• Foreskin adhesions break down and form smegma pearls (white cysts under the foreskin) which are then extruded
aetiology of phimosis
- Age 2-6 = normal physiology
- Injury
- Balanitis
- STIs
- Diabetes
- Eczema
- Psoriasis
- Lichen planus
- Lichen sclerosis
clinical features of phimosis
- Erythema (balanitis)
- Pain (balanitis)
- Swelling (balanitis)
- Ballooning during urination
- Painful erection
- Haematuria
- Recurrent UTIs
management of phimosis
• <2 years: watch and wait as normally self resolves
• Good hygiene – wash regularly with plain, warm water
• Avoid irritants + use lubrication during sex
1) Corticosteroid cream/gel/ointment
2) Surgical release of adhesions
2) Circumcision
what are the stages of syphilis
primary secondary
terriary
aetiology of syphilis
treponeum pallidum (spirocheate bacterium)
seuxally or vertical transmitted
white men
MSM
aged 25-34
clinical features of primary syphilis
- 10 – 90 days post-infection, resolves over 3-8 weeks
- Solitary, painless, genital ulcer (chancre)
- Inguinal lymphadenopathy
clinical features of secondary syphilis
Secondary:
• Latent syphilis = People with untreated syphilis but no symptoms or signs of infection have latent syphilis 4-10 weeks after initial chancre
• Early stage = disease has been present for less than 2 years
• Late stage = disease has been present for more than 2 years.
- Generalised polymorphic rash affecting palms and soles - symmetrical and non-itchy. Can be macular, popular (coppery red), papulosquamous, and, very rarely, pustular
- Generalised lymphadenopathy
- Genital/oral condyloma lata (highly infectious wart like lesions on the genitals or mouth)
- Hepatitis, splenomegaly, glomerulonephritis
- Acute meningitis, CN palsies, uveitis, optic neuropathy etc.
clinical features of tertiary syphilis
- Presents in up to 40% of people infected for >2 years.
- Neurosyphillis
- Meningovascular = Headache, 3rd/6th/8th CN involvement, papilloedema, hemiplegia.
- Parenchymatous = tabes dorsalis ( ataxia, failing vision, sphincter disturbnces severe attacks of ‘lightening’ pain, degeneration of the posterior column absent ankle and knee reflexes, impaired virbration and position sense, +ve Romberg sign) and general paraesis (early irritability, fatigability, personality changes, headaches, impaired memory, tremors. Late lack of insight, depression or euphoria, confusion and disorientation, delusions, seizures, transient paralysis
- Signs: expressionless faces, tremor of lips, tongue and hands, dysarthria, impairement of handwriting, hyperactive tendon reflexes, pupillary abnormalities, optic atrophy, convulsions, extensor plantar responses)
- Cardiovascular syphilis
- aortic regurgitation common), aortitis (with or without coronary ostial stenosis), aneurysm of the ascending part
- Gummata = inflammatory plaques or nodules (found in the skin or bones) that develop 3-12 years after the primary infection. Painless lesions that are indolent, firm, coppery red and about 0.5-1cm in diameter.
clinical features of syphilis
- 8th Nerve deafness
- Hutchinson’s incisors
- Interstitial keratitis
- Rash (maculorpapular, bullous and desquamation)
- Hepatosplenomegaly
- Syphillitis snuffles
- Periositis
- Sabre shins
investigation for syphilis
- Serological testing
- Smear from the primary lesion for PCR testing
- Screen for other STI’s
management of syphilis
- Benzathine penicillin 2.4 MU single dose IM (used in pregnancy) – duration depends on which stage it is in
- Contact tracing (potentially over several years)
- Refrain from sexual intercourse until partner is treated.
what is erectile dysfunction
persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
physiology of an erection
- Erection occurs due a neurovascular mechanism
- control of the smooth muscle tissue of the corpora cavernosa by the autonomic system
- Swelling is due to a reduction in the alpha-sympathetic tonus of the cavernous tissue permitting influx of arterial blood, and to decreased venous flow from compression of the subalbugineal venous network against the tunica albuginea of the corpus cavernosurn
- Once this obstruction to the venous return has been achieved, the arterial flow in the corpora cavernosa decreases but persists
- Rigidity is due to an increase in intracavernous arterial pressure simultaneous with contraction of the perineal muscles (ischiocavernosus) under the somatic control of the pudendal nerve
what are the nerves supplying the penis?
• Innervation via sympathetic (thoracolumbar segment T11-L2) and parasympathetic (sacrum S2-4) fibres
aetiology of erectile dysfunction?
vasculogenic - CVS, HTN, hyperlidiaemia, DM, smoking, major pelvic surgery to do with prostate
neurogenic (central) - MS, parkinson’s disease and multiple atrophy, stroke, spinal cord trauma
neurogenic (peripheral) - DM, CKD, polyneuropathy, major surgery of the pelvis, urethral surgery
Structural - Peryonie’s disease (inflammatory condition resulting in deformity and bending of penis, penile cancer, micropenis
hormonal - hypogonadism, hyperprolactinaemia, hyperthyroidism, hypothyroidism, Cushing’s diseas, MEN
Psychogenic
drugs - antiHTN - b blocker, verapamil, diuretics, antidepressant, anti-arrhythmic drugs, antipsychotics, ranitidine, recreational drugs
what are the different cardiac risk stratification for erectile dysfunction
low risk - no significant cardiac risk associated with sexual activity
intermediate risk - men with uncertain cardiac condition
high risk - cardiac condition that is sufficiently severe/unstable for sexual activity
investigation for erectile dysfunction
international index for erectile function (also diagnostic criteria)
HbA1c, lipid profile, total testosteron (if low/borderline –> FSH,LH and prolactin) , PSA (if PR abnormal and > 50 yrs old)
management of erectile dysfunction
low risk - management in primary care
intermediate risk - specialist testing
high risk - cardiac assessment and treatment, stop sexual activity until cardiac conditions have been stabilised/cardiologist says is okay to resume
changes to lifestyle and drugs
PDE-5 inhibitors eg Sidenafil
- take around 1 hour before sex
- contra - severe/unstable heart diseaes, hypotension, unstable angina/agina during sexual intercourse, recent stroke/MI, sever hepatic impairment, herediatary degenerative disorder
vacuumed erection device - urology review
intra- cavernous injection eg aprostadil
penil prosthesis - urology
what are some side effect of sidenafil
back pain dyspepsia flushing migraine mylagia nasal congestion dizziness N+V visual disturbances sudden hearing loss priapism (>4h)
interaction - nitrate, alpha blockers
what is epididymo-orchitis
Epidiymitis = inflammation of the epididymis
Orchitis = inflammation of the testes
aetiology of epididymo-orchitis
multiple partners anal intercourse C.coli infection chlaymdia gonorrhoea mumps elderly - due to BPH TB
clinical features of epididymo-orchitis
- gradual onset (hours to days) pain
- duration < 6 weeks
- usually unilateral
- palpable swelling of the epididymis +/- testis
- dragging/heavy sensation
- painful and tender
- Prehn sign (relieve of pain when elevatino of the testes_
if infected by TB
- painless
- non-tender
- epididymis is hard with an irregular surface
- spermatic cord is thickened
- vas deferens feels hard and irregular
can have urethral discharge, hydrocele, erythema, symptoms of UTI, parotid swelling (mumps)
Ix for epididymo-orchitis
urine dip +/- MSC swab of secretion NAAT urine HIv + Syphilis screen USS PR exam
management of epidiymo-orchitis
suspected TB - specialist referral
Abx if bacterial +/- analgesia
tight underwear for scrotal support
abstain from intercourse
what is urethritis
inflammation of the urethra
what are the 2 different types of urethritis
1) gonococcal - caused by neisseria gonorrhoea
2) non-gonococcal - eg by chlamydia
what is post gonococcal urethritis
occurence of non-gonococcal urethritis after curative treatment of gonococcal urethritis
aetiology of urethritis
gonorrhoea and chlamydia risk factor
STI
- aged 15-24
- female
- new/mutple sexual partner
- inconsistent use of condoms
- low SES
trauma
UTI
clinical features of urethritis
dysuria
urethral discharge - white or green
pruritus at the end of the urethra
orchalgia - heavy sensation in the male genitalia
Ix for urethritis
urine dip - +ve leukocytes
NAAT swab for gonorrhoea and chlamydia
Gram stain of urethral discharge/urine sediment
- +ve for gram -ve diploccoci = gonorrhoea
standard STI screen +/- HIV +/- Hep B +/- Hep C testing
management of urethritis
if gonorrhoea - IM ceftriaxone 250mg and azithromycin 1g orally
if chlamydia - doxycycline 100mg BD for 7 days
abstain from sexu until partner notified and complete of treatment - 7 days
what are the 2 categories of testicular cancer?
germ cell tumours - 95%
- seminoma (50%) - slow growth, more sensitive to radiation. good prognosis
- non-seminoma - individual or mixture of cell tumour - fast growth and spread
- teratoma (50%), embroyonal carcinoma, choriocarcinoma, york sac tumours
Non-germ cell tumour -5%
- leydig cell tumours
sertoli cell tumours
where is testicular tumours likely to metastasis to?
lymphatics, lungs, liver, brain
aetiology of testicular tumours
- 15-40 yrs old
- cryptorchidism - 1 or both testes fail to descend to the scrotum
- germ cell neoplasia in situ (GCNIS)
- FHx
- klinefelter syndrome
- Down’s syndrome
- caucasian
clinical features of testicular cancer
- painless lump/swelling
- dull ache in the groin/abdomen
- dec sensation
- hard testicle without fluctuance/translumination
- irregular
investigation of testicular cancer
USS
tumour marker
- alpha-fetoprotein (inc in yolk sac tumours/teratoma)
- beta-hCG (inc in yolk sac tumours/teratomas)
- lactate dehydrogenase (inc in 20% of seminomas)
staging - CXR CT MRI radial inguinal orchiectomy of the affected side
management of testicular cancer
active surveillance
orchiectomy + testicular prosthesis
adj chemo/radio
stem cell transplant
monitor post-treatment with tumour markers and imaging
what is cryptorchidism
undescended testis - • Incomplete migration of the testis during embryogenesis from the original retroperitoneal position (near the kidneys) to its final position in the scrotum
what are the types of cryptorchidism?
true (on the tract of descending but stuck) - abdominal, inguinal, supra-scrotal
ectopic (not on a tract of descending) - prepenile, femoral
aetiology of cryptorchidism?
FHx
low birth weight
preamature
classification of cryptorchidism
- Undescended but palpable
- Retractile – can be pulled into the scrotum and remains there upon the release of traction
- Cryptorchid
- Unilaterally non palpable
- Bilaterally non palpable – normal penis (if abnormal, refer immediately for disorder of sex development work up)
management of cryptorchidism
• Referral by 6 months for surgical correction within the 1st year
what is hypospadias
the urethra opens on the undersurface of the penis
more serious if at the shaft of the penis
aetiology of hypospadias
• Due to partial/abnormal closure of the urethra during any part of the development
management of hypospadias
corrected via surgery
circumcision is contra-indicated in infancy with this condition
what is breast fibroadenoma
benign lump of glandular and fibrous tissue - develops from a whole lobule
consider part of normal physiology
what are the different types of breast fibroadenoma
simplex - all the same cell type
complex - different cell type
giant - > 5 cm
juvenile - in teenagers
what does the growth or regression of breast fibroadenoma depend on?
oestrogen and regress after menopause
aetiology of fibroadenoma
< 35
unknown
clinical features of fibroadenoma
painless
breast lump
smooth, well circumscribed, firm, mobile mass (aka breast mouse)
investigation for breast fibroadenoma
tripel assessment
breast examination
mammogram - well defined mass, may have popcorn like calcifications
USS +/- fine needle aspiration/core needle biopsy
what is the investigative pathway for <35 and suspected breast fibroadenoma
Triple assessment (no mammography)
if not compatible with FA - excise
if compatible with FA
- follow up every 6 month until 35
- if regress - follow up until complete regression
- no change at age 35 –> excise
- if enlarge –> excise
what is the investigative pathway for >35 and suspected breast fibroadenoma
triple assessment
if not compatible with FA - excise
if compatible with FA
- follow up every 6-12 months
- if complete regression - routine follow up
- if incomplete regression - excise
- if enlarged - excise
what is fat necrosis of the breast?
breast tissue being dmaged by breast biopsy, readiotherapy, breast surgery
typically firm and round but may present as irregular, mostly painless, skin tethering
will break down on its own over time
management of breast fibroadenoma
conservative management - may disappear on their own
excision biopsy to remove
vacuum assisted mammotomy
alternative - high intensity focused US
what is another name for breast abscess?
puerperal mastitis
what is breast abscess
localised area of infection with a walled off collection of pus
Puerperal mastitis = mastitis (inflammation of the breast tissue with lactational)
aetiology of breast abscess
S.aureus infection breastfeeding sore/cracked nipples nipple piercing milk stasis
periductal mastitis - subareolar ducts are damaged/infected
Duct ectasia - dilation of the large breast duct, common around menopause, lump around areola +/- green nipple discharge
diabetes (immunosuppression) HIV (immunosuppression) RA trauma corticosteriod treatment
granulomatous lobular mastitis (GLM) - autoimmuen reaction to substances secreted from mammary ducts
poor soci-economical status
poor hygeine
clinical features of breast abscess
painful, swollen lump in the breast - redness, hot, swelling of the overlying skin
pus discharge from the nipple
fever
flu like symptoms
malaise
investigation for breast abscess
breast exam
USS
culture of fluid from the abscess
breast milk culture
what is a fibrocystic disease of the breast?
lumpy breasts that fluctuate with the menstrual cycle
aetiology of fibrocystic disease
• Obesity, nulliparity, OCP, late-onset menopause, later age of 1st child
clinical features of fibrocystic disease
• Constant, dull pain/tenderness (can be cyclical) bilaterally, symmetrical lumpiness
management of breast abscess
Continue breast feeding if possible, improve milk removal via breast feeding technique, do not wear a bra at night
2) Antibiotics
2) Analgesia
3) Incision and drainage via US guided needle aspiration/surgical drainage
what are the different types of breast cancer?
Ductal carcinoma in situ - precancerous epithelial cells of the breast duct (30% will become cancerous)
Lobar carcinoma in situ = precancerous, typically in premenopausal women - 30% will become cancer
cellular dysplasia in situ - invasive –> ductal carcinoma, lobar carcinoma, inflammatory
where does breast cancer mets to?
2Ls and 2Bs
Liver
lung
brain
bones
aetiology of breast cancer
unopposed oestrogen - ir HRT, COP
obesity, hx of breast cancer, breast augmentation, nulliparity, 1st child after age of 30, age, FHx, BRACA1/2 gene
breast feeding = protective
History ALONE
- past hx of breast cancer, FHx
- Abortion/age
- late menopause
- obesity
- nulliparity
- early menarche
clinical features of breast cancer
painless dense lump puckered/indrawn nipple Peau d'orange - oedema skin red and warm = inflammatory carcinoma discharge - bloody lump under the arm
Paget’s - nipple eczema, erythematous, scaly rash (associated with invasive ductal carcinoma)
what is the screening programme for breast cancer like?
mammogram for women aged 50-70 every 3 years
high-risk patients
- strict criteria for referral foe genetic testing
- annual mammograms
- annual MRIs
investigation of breast cancer
Triple Assessment
breast examination
bilateral mammogram +/- FNA - more effective in older women, picks up calcifications
USS of breast and regional lymph node +/- FNA
monoclonal antibody techniques - to identify PR, OR o HER2 receptors
staging - CT, CXR
what are some differentials for breast cancer
fibroadenoma
fibrocystic disease
benign breast disease eg breast cyst
intraductal papilloma - the commonest cause of blood-stained nipple discharge in younger women, no palpable mass
mastitis
fat necrosis of the breast
management of breast cancer
surgery - lumpectomy or wide local excision or mastectomy +/- axillary clearance\
sentinel node biopsy during surgery
radio post-surgery, chemo can be neoadjuvant, adjuvant, treatment of mets
if oestrogen receptor +ve - Tamoxifen
if ER +ve and post-menopausal
- anasrozole
HER2+Ve –> IV trastuzumab (herceptin)
