Staging: Stage I < 2 cm, no nodes/mets

Staging: Stage I < 2 cm, no nodes/mets

Stage III direct spread, nodes

Stage IV disseminated mets
Patient Age: < 35 fibrocystic / fibroadenoma / mastitis

35-50 fibrocystic / carcinoma / fibroadenoma

> 50 carcinoma / fibrocystic / fat necrosis
Risk Factors:

Nulliparity (women who are pregnant by age 18 have 30-40% reduced risk)

Menarche (menarche at 16 confers 40-50% reduced risk vs. menarche by 12)

Early menopause (occurring by age 40 reduces risk by 35%)

Duration of maternal nursing (longer nursing decreases risk)

Obesity increases risk

previous h/o breast Ca (2x risk in contralateral breast)

FH of breast CA / BRCA1/BRCA2 confer 10x risk (breast, ovary, colon)

• 
  Suspicion of genetic carrier (can get testing)
  

20-40 medical exam (physical breast exam) every 3 yrs

35-40 baseline mammogram (30-40 with FH, or 10 yrs ahead of age of 1^o relative)

40-50 mammogram every 2 yrs

50 mammogram yearly

• 
  suspicious lump < 35 yrs  likely need U/S
  
  • 
    if seems like simple cyst on U/S or seems benign on exam, can watch for regression with next menstrual cycle, but if it doesn’t go away  FNA, core biopsy or excisional biopsy
    
  • 
    if cyst regrows or mass effect does not resolve post FNA, then need to get excisional biopsy
    
  • 
    positive mammogram  biopsy
    
  • 
    suspicious lump in pt > 35 yrs or more risk factors  proceed with U/S, FNA, referral to specialist
    
  • 
    during pregnancy (persistent lump NOT normal; seek attention)
    

(DCIS) BRCA2 women (breast) and men (breast/prostate) / higher in Ashkenazi Jews

Rad 51 tumor suppressor

p53 tumor suppressor

PTEN

Her-2/neu (erbB2) – aggressive behavior of tumor

Stage I  modified radical or lumpectomy + radiation +/- hormonal

Stage II  surgery + adjuvant (hormonal and/or chemo)

Stage III, inflammatory, poor histological features  chemo/hormonal before surgery

Advanced, metastatic disease  ~surgery + chemo (definitely)

• 
  Chemotherapy
  

AC (adriamycin, Cytoxan)

CMF (Cytoxan, MTX, 5FC)

Paclitaxel (Taxol)

Docetaxel (Taxotere)

Gemzar* (new)

Xeloda (oral 5FU transformed in liver)

• 
  Herceptin (new agent)
  

Used as single agent in chemo-resistant metastatic disease

Combination with chemotherapy in primary or 1^st recurrent cancer

Toxicity: cardiomyopathy (do not use with doxorubicin)

• 
  High-dose chemo + autologous bone-marrow (remains controversial)
  

modified radical or lumpectomy both involve axillary node dissection or sentinel node sampling / extensive lymph node resection (levels I, II and III) can lead to massive/chronic lymphedema (20-30% of patients), which can increase relative risk of angiosarcoma (rare to begin with) [dermis] / decision between lumpectomy versus modified radical also depends on exact tumor location in breast and if patient has access to radiation treatments

Raloxifene (Evista) – similar action to Tamoxifen / large scale studies ongoing

Progesterone (Megase)

Aromidase inhibitors – newer, use increasing (exemestane)

• 
  overall 10 yr survival 50% / stage I – 80% II – 60% III – 20%
  
• 
  Estrogen/progesterone receptors increase survival (E+ and E+/P+ tumors respond to hormonal agents/oophorectomy with 70% regression)
  

Pap, lipid panel, mammogram, TSH, UA, r/o glaucoma, osteoporosis screening

Colon Ca: same as for men

Immunizations: Fluvax q yr (> 55 yrs), pneumovax x 1 (65 yrs)

Cardiovascular: “Women’s Healthy Study 2005” to address use of ASA for low-risk pts in MI prevention (did not decrease MI but did decrease CVA)
Pap Smears

need annual initial but after 3 negative annuals, can consider decreasing to every 3 years in low-risk patients / if suspicious findings, repeat in 3-4 months, check HPV DNA typing or colposcopy depending on patient’s specific clinical/history

Diagnosis: in females with long-standing incontinence, may not need workup, but if male or abrupt onset or pain, do cystometrics and/or other workup (cystoscopy) to rule out stones, tumor, infection)

• 
  Stress incontinence (F)  surgery
  
• 
  Detrussor overactivity (M/F)  behavioral first, then if necessary, meds (oxybutynin, tolterodine) but careful not to cause retention, avoid indwelling catheters
  
• 
  Urge incontinence (M/F)  behavioral first
  
• 
  Functional incontinence (M/F)  behavioral first
  
• 
  Overflow incontinence (M: obstruction, prostate, M/F: atonic bladder)  workup/treat
  

always new trends in hormone replacement therapy [NEJM]

Note: can stay on OCP for birth control needs until age 50-52 then stop for 7 days and measure FSH, if elevated, pt likely menopausal, then pt can decided whether to start HRT or wait (OCP not recommended if pt has side effects or RF’s such as smoking, DVT, heart disease)

Risk factors: decreased adipose (decreased estrone), abrupt failure

Hot flashes result from daily LH surge (lack of negative feedback)
Obstetrics
Drugs that are teratogenic (see pharm)
Ectopic Pregnancy (see other)
Pregnancy and specific diseases

• 
  Thyroid disease and pregnancy (hypothyroidism)
  
• 
  Liver disease and pregnancy (see below)
  
• 
  Renal disease and pregnancy
  
• 
  Diabetes and pregnancy (see below)
  

SLE, migraines

• 
  Hyperemesis gravidarum (1^st)
  
• 
  Cholestasis (2^nd/3^rd)
  
• 
  HELLP (3^rd trimester)
  
• 
  Acute fatty liver of pregnancy (3^rd)
  

• 
  increased risk of IUGR, prematurity, preeclampsia
  
• 
  Cr 1.4 – 2.0  2% chance of worsening renal function with pregnancy (30% if Cr > 2)
  

macrosomia or IUGR / all organs larger (exc. CNS) / increased sub-cutaneous fat / hyperplastic islets, neonate becomes hypoglycemic / clinically reversible, dilated or obstructive cardiomyopathy / increased liver lipid, glycogen increased fetal adrenal cortex, leydig and theca / increased malformations (congenital heart defects) / fetal death 10-30%

screen everyone / dietary measures usu. sufficient for mild gestational diabetes / if cannot maintain < 105 fasting or < 120 2 h postprandial, should use careful insulin (oral hypoglycemics contraindicated) / after pregnancy, must follow for increased risk of eventually developing diabetes

• 
  cortisol is elevated in pregnancy / cortisol levels in 2^nd and 3^rd trimester may overlap with Cushing’s syndrome
  
• 
  use metyrapone to suppress cortisol if needed (ketoconazole is teratogenic)
  

2 hr no dilatation (with adequate contractions: q 2-3 mins lasting 60 seconds or 200 montevideo units)

bleeding  C-section

stop bleeding < 36 weeks – amnio FLM  C-section


Male Reproductive System

Penis Infections

Prostate BPH, prostate CA

Testes testicular infection, testicular cancer
Penis
Note: male circumcision shown to reduce risk incidence of HIV by ½ in studies in Africa
Malformations

hypospadias / epyspadias / phimosis (natural stricture) – physiological adhesions usually resolve on their own at an early age / paraphimosis (follows forcible retraction of phimosis)

inflammation, infection due to phimosis/paraphimosis

ceftriaxone 250 mg IM (in order to achieve high enough systemic levels) / regular penicillin

won’t cut it
Syphilis (see micro)

1) chancre 2) condyloma lata (highly infectious) 3) gummatous

1. 
   Papule – painless, transient
   
2. 
   Inguinal syndrome – lymphadenitis with bubo (painful, progresses to abscess, ruptures) / fever, malaise, anorexia [Groove sign between matted groups of lymph nodes]
   
3. 
   Anogenital syndrome – anal pruritis, proctocolitis, rectal stricture, rectovaginal fistula, genital ulcer, elephantiasis
   

Micro: GNR, encapsulated, intracellular / cannot be cultured on solid media

Transmission: may be transmitted by fecal-oral as well as sexually

lesions) / often with painful, inguinal lymphadenopathy / can form large ulcer if left

untreated

Diagnosis: culture difficult (transport swab in Amies, Stuart, chocolate agar) / gram stain:

gram negative “school of fish”

HPV 6, 11 / benign / koilocytes

HPV 6, 11 / diagnosis: endophytic (invasive) growth w/ lack of normal vessels

Treatment: excise, (do NOT irradiate)
Carcinoma In Situ (CIS)
Bowen’s disease [pic][dermis]

> 35 both sexes / plaque / 10% progress to squamous carcinoma

plaque on glans/foreskin / 10% progress to squamous carcinoma

younger / multiple papules / mistaken for condyloma acuminatum

usually glans / lymphatic spread / exophytic (better prognosis)

Risk factors: lack of circumcision / poor hygiene / phimosis / HPV 16,18 / UV light

Treatment: surgical, radiation, ?chemotherapy

Regional radiation therapy is curative in up to 5% / chemo not generally useful