Rosh Reproductive

MC benign tumors of the breast

fibroadenomas

Fibroadenomas typically start occurring at what age?

15 y/o

dz: classically round, well-circumscribed, mobile, firm, rubbery and non-tender tumor of breast

fibroadenoma

Fibroadenomas fluctuate in size with what factors?

menses;

OCP use;

pregnancy

A 24 y/o F presents to the clinic complaining of worsening irritability, feelings of hopelessness, easy fatiguability, bloating, and issues concentrating. She says she is very overwhelmed. These sxs occur the week before she menstruates and it has been interfering w/ her work. What is the most likely dx:

premenstrual dysphoric disorder;

premenstrual syndrome

premenstrual dysphoric disorder—severe form of PMS

one of the main sxs include feelings of hopelessness

additional sxs include easy fatiguability, physical sxs (bloating), difficulty concentrating, very overwhelmed —need at least 4

Sxs must improve after the onset of menses and become minimal OR absent after menstruation.

To be considered a dx, it has to interfere w/ the pt’s life (work, school, socially).

dz: severe form of PMS

premenstrual dysphoric disorder

How many sxs must be present in premenstrual dysphoric disorder in the final week before the onset of menses?

one of the following:

1. mood swings and marked affective lability

2. irritability/ anger w/ an increase in relational conflicts

3. anxiety/ tension

4. feelings of hopelessness/ depression

plus pt must have at least 4 of these additional sxs:

• decreased interest in activities

• easy fatiguability

• change in appetite or sleep habits

• physical sxs (bloating, weight gain etc)

• difficulty concentrating

• feelings overwhelmed

Which of the following is a concerning (pathological) fetal HR tracing finding:

moderate baseline FHR variability;

induced accelerations;

early decelerations;

recurrent late decelerations

recurrent late decelerations

The first 3 are normal FHR findings.

Other pathological findings include:

no variability;

variable decelerations;

bradycardia/ sinosoidal pattern

Dz: a rare type of breast malignancy that presents w/ characteristic dermatologic manifestations

inflammatory breast CA

Which kind of mammogram is indicated if a pt is suspected to have inflammatory breast CA of one side?

diagnostic mammogram: affected breast;

screening mammogram: nonaffected breast

At the time of inflammatory breast CA dx, pts should also receive a CT scan of what body parts?

chest;

abd/pelvis as well as a bone scan d/t distinct METS dz

MC tx regimen of inflammatory breast CA

neoadjuvant chemo (doxorubicin and cyclophosphamide followed by paclitaxel) followed by mastectomy and subsequent radiation therapy.

Why is immediate breast reconstruction not recommended for a pt being treated for inflammatory breast CA?

d/t high risk of local recurrence

What class of meds is preferred for adjuvant therapy in postmenopausal women w/ HER + breast CA?

aromatase inhibitors (anastrozole, letrozole or exemestane)

What labs should be drawn for a male pt w/ gynecomastia?

serum beta-human chorionic gonadotropin levels (r/o testicular tumor or other malignancy that may be producing exogenous hormones);

prolactin (r/o prolactinoma)

What should be asked to a male athlete experiencing gynecomastia?

use of anabolic steroids which can lead to gynecomastia in 50% of individuals

What do you do with a mild degree of pubertal gynecomastia in teenagers?

This is normal and usually resolves w/o tx in 1-2 years

Tx of true glandular gynecomastia

SERM (raloxifene or tamoxifen)

Which sex chromosome anomaly is suspected in male individuals with persistent gynecomastia and small testes, particularly in those w/ language-based learning difficulties?

Klinefelter syndrome (47, XXY)

If gynecomastia is seen in a neonatal child, how long does it take to resolve?

4-8 weeks

A 29 y/o F presents to the office w/ a 3-day hx of redness and tenderness to the L breast. She is breastfeeding her 2-month-old infant, who has been having difficulty w/ his latch. Her medical hx includes HIV infection. Her viral load is undetectable. Vitals are WNL. PE reveals a firm, erythematous, and tender patch of inflamed skin around the L nipple. Which of the following is the most appropriate therapy for the suspected condition:

dicloxacillin

Bactrim

Bactrim

dz: mastitis

Pt has HIV which is a RF of MRSA so the best tx option is Bactrim and clindamycin (clindamycin has been having increased rates of resistance).

When mastitis or breast abscess is present, breastfeeding pts w/ HIV should pump and flash heat the breastmilk prior to feeding the infant or discard milk from the affected breast and feed only from the unaffected breast until fully recovered.

Dicloxacillin is an option for pts w/ nonsevere mastitis w/o MRSA RFs.

What is the primary cause of mastitis?

clogged milk ducts leading to inefficient drainage of milk during breastfeeding

RFs of developing MRSA

HIV infection;

IVDA;

abx use in the past 6 months

What potentially fatal condition should be considered when diagnosing a pt w/ mastitis?

inflammatory breast CA

A pt who is 40 y/o just had a screening mammogram. When should she get one again?

every 2 years unless certain symptoms or PE findings arise

What finding caused by vaccination w/ COVID-19 mRNA vaccines can impact the interpretation of mammography?

transient axillary lymphadenopathy

MC type of breast CA

invasive ductal carcinoma

What is the breast-conserving therapy for breast CA?

lumpectomy followed by radiation therapy

A 55 y/o F presents to the oncology clinic to discuss therapy options for newly diagnosed, nonmetastatic, unilateral invasive breast CA. Routine analysis reveals estrogen receptor + and progesterone receptor + tumor expression. What is the recommended therapy for this pt:

endocrine therapy + mastectomy;

radiation therapy + radical mastectomy

endocrine therapy + mastectomy

Endocrine therapy, chemo or biologic therapy are all systemic adjuvant therapy options that can be used to tx breast CA in additional to surgical therapy and radiation.

Tamoxifen, an estrogen receptor modulator, significantly reduces the risk of recurrence and death in pts w/ estrogen receptor + dz, such as this pt.

Breast CA management guidelines recommend that analysis of both estrogen & progesterone receptors should be routinely performed in all invasive breast CAs b/c tumor expression can best predict which pt will benefit from endocrine therapy. Estrogen receptor - and progesterone receptor - tumors are unlikely to respond to endocrine therapy.

Progesterone receptor status is heavily dependent on estrogen receptor status and does not seem to have independent predictive value when the estrogen receptor status is unknown.

The goal of radiation therapy is to eradicate any residual CA remaining following breast-conserving therapy. Radical mastectomy would not be recommended in a pt w/ unilateral, noninvasive, nonmetastatic breast CA.

What is the correct systemic therapy for a human epidermal growth factor receptor 2-positive breast CA?

Trastuzumab, a monoclonal Ab, that targets human epidermal growth factor receptor 2

Gynecomastia results from a relative imbalance of what?

between estrogen & testosterone levels