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diffusely nodular (eg, cordlike thickening) breasts and bilateral, nonfocal

premenstrual tendernes
o fibrocystic changes
78 year old nursing home urinary incotinence, less mobile, solment,
normal temp, disoreiented, thin vaginal mucosa - managing uti next step
o urinalysis+culture
ovarian mass categorizing as malignant or benign
o ca-125 then w/pelvic ultrasound
33 year old w/amenorrhea of 9 months, no symptoms, had tubal ligation
aka not pregnant, 254lbs, obese, lab tests normal fsh and lh, cause of
o anovulation
fsh, lh normal, ovariies still produce estrogen
progesterone not produced normally
no progesterone withdraw
following leep or cryotherapy
o Followup Pap smears are performed every 6 months for 2 years to
ensure that the dysplastic changes do not return
o Subtotal or supracervical hysterectomy
removes only the corpus of the uterus
leaving the cervix in place
o Total hysterectomy = simple hysterectomy
o Radical hysterectomy
early-stage cervical carcinoma
uterus, cervix, and surrounding tissues, including cardinal
ligaments, uterosacral ligaments, and the upper vagina
o to biopsy lesions or to resect submucous leiomyomas, polyps, or
uterine septa
woman breast feeding first noticed redness a wee ago, worsened, exam
shows patch of erythema patch from areola, 3cm FLUCTANCE,
o needle aspiration + antibiotics
diclo, cephalexin
Premenstrual Dysphoria
Diary of symptoms for >2 cycles
temporal relationship of symptoms to cycle is important
Selective serotonin re-uptake inhibitors (SSRIs)
severe PMS, PMDD
paroxetine is contraindicated in pregnancy
first trimester exposure may lead to congenital heart disease
Drospirenone + ethinyl estradiol (Yaz; Yasmin)
drospirenone is a spironolactone analog
antiandrogen and antimineralocorticoid effects
Gonadotropin-releasing hormone agonist (GnRH agonist)
Premenstrual Syndrome (PMS)
mostly occur 2 weeks before her menstruation
disappears with menses
more severe affective changes in premenstrual dysphoric disorder (PDD)
o symptom diary the patient keeps throughout 3 menstrual cycles
o temporal relationship
o symptoms:
recurrent in at least 3 consecutive cycles
absent in the preovulatory phase of the menstrual cycle
present in the 2 postovulatory weeks
interfere with normal functioning
resolve with onset of menses
o secretory stage = symtpoms
o proliferative (variable length) = NO symptoms
fluoxetine, alprazolam (Xanax), and GnRH agonists have been shown in
controlled, double-blind trials to be superior to placebo for the more severe
Yaz (drospirenone/ethinyl estradiol)
o progestin, drospirinon (DRSP)
o monophasic
o only a 4 day hormone-free
o DRSP = analogue of spironolactone
both antimineralocorticoid and antiandrogenic effects
12 months of amenorrhea
elevation of gonadotropins (FSH and LH)
mean age 51
o smokers experience menopause up to 2 years earlier
o 3040
o mostly idiopathic but can occur due to:
radiation therapy or surgical oophorectomy
<30 = autoimmune or Y mosaicism
hot flashes
o profuse sweating and sensation of heat
hypothalamic thermoregulatory center

All estrogen agonists (eg, tamoxifen, raloxifene, estrogen-containing oral

contraceptives) Increase the risk of venous thromboembolism by increasing protein C
o Estrogen = promotes the growth ducts
o Progesterone = stimulates development milk producing alveolar cells
o Prolactin = stimulates milk production
o Oxytocin = ejection from the lactating breast
Contraceptives Absolute contraindications estrogen OCPs
levonorgestrel-contalnlng Intrauterine device (IUD) Cardiovascular
o progestin Thromboembolism
physical barrier by thickening cervical Coagulopathy, antiphospholipid
mucus antibodies
impairing implantation through Coronary heart disease
decidualization of the endometrium. H has Stroke
an efficacy Arterial hypertension (> 160/95 mm Hg)
o efficacy >99% Heart defects
o used for 5 years ^^^hypertriglyceridemia
o side effect: amenorrhea Metabolic disorders of the liver
can be used to improve anemia and Insulin-dependent diabetes mellitus
abnormal uterine Oncologic: Hepatic, estrogen+
bleeding. A small percentage of women experience Acute pancreatitis
systemic side effects (eg, mood Lupus erythematodes
changes, breast tenderness, headaches). Weight gain is not Vasculitis
a side effect After herpes gestationis
Copper IUD Smoking > 35 years of age
o best emergency contraceptive Genital bleeding of unknown cause
emergency contraceptive Uterine leiomyomas (intracavitary)
o best copper iud Gastric/duodenal ulcer
o less effectiive in obese or overweight 4x failure rate Ulcerative colitis
o levonorgestrel - otc
o antiprogestin - ulipristal - not otc
o yuzpe regimen - ehtinyl estradiol + levon
common side effects
o progestin
break through bleeding - most common
reason to discontinue
follicular cysts
vte - due to ^ estrogen activity
o estrogen
vte + cv
hypertension - ^angiotensin in liver
headaches, hepatic adenoma, mastopathy,
dynia, nausea
DMPA is not appropriate for patients who wish to regain
fertility soon
Implants and IUDs can be used but may not be cost-
Postpartum contraception:
o all contraceptive options except for combination
OCPs can be considered in the postpartum period
o OCPs containing estrogen should not be given if
estrogen may reduce breast milk
production and enter the milk itself
o Combination OCPs may only be used after 46
weeks postpartum
o 18 yr old, pain worse on 2nd day, no main ocps - diagnosis?
pelvic congestion
o pain peaks BEFORE MENSES, dyspareunia, infertiliity
dull and ill defined pelvic ache
o Up to one-third of patients are asymptomatic.
o Chronic pelvic pain that worsens before the onset of menses
o Dysmenorrhea
o Pre- or postmenstrual bleeding
o Dyspareunia
o Infertility
o Dyschezia
o Endometriosis may be asymptomatic incidental finding
o Patient history, Physical examination CASE: woman with pelvic pain, Physical
Rectovaginal tenderness examination shows a normal-size uterus
Adnexal masses and an enlarged left adnexa.
o Transvaginal ultrasound (best initial test) Ultrasonography
The uterus is generally not enlarged. reveals a homogeneous cystic-appearing
Evidence of ovarian cysts (chocolate cysts) mass on the left ovary but is otherwise
Nodules in bladder or rectovaginal septum normal.
o Laparoscopy (confirmatory test) ENDOMETRIOSIS
o severity of findings does not correlate w/severity symptoms
o Medical therapy
nsaids - alone if wants preg OR w/OCPs
Severe symptoms
GnRH agonists (e.g., buserelin, goserelin)
and estrogen-progestin OCPs
Surgical therapy
First-line: laparoscopic excision
Second-line: open surgery hysterectomy +/-
bilateral salpingo-oophorectomy
o bulky, globular
o Epidemiology: peak incidence at 3550 years
o risk factors have been identified:
Uterine fibroids
o Clinical features: May be asymptomatic
Chronic pelvic pain, aggravated during menses
Uniformly enlarged uterus, tender on palpation
o Diagnostics: clinical+supported by transvaginal US+MRI
Asymmetric myometrial wall thickening
Myometrial cysts
o Histology serves to confirm the diagnosis.
o Treatment: Conservative=OCPS progestin-only
contraception (e.g., IUD, continuous-use contraceptive
pill), NSAIDs for pain relief
o Surgical: Hysterectomy is the definitive treatment
Bartholin Cyst
2% of women are affected at some point in their lives by a Bartholin gland cyst or abscess.
Peak incidence: 2030 years
Pathophysiology: blockage of the duct by inflammation or trauma
Clinical findings: pain during intercourse, tenderness upon palpation
o Pelvic exam: unilateral, palpable mass in the posterior vaginal introitus
o Biopsy is indicated if any of the following apply :
> 40 years of age
o Progressive, solid, and painless mass found during pelvic exam
o Not responsive to treatment
o History of malignancy in the labia
o Sitz baths to facilitate rupture of the cyst
o Consider surgery for symptomatic cysts
A Bartholin gland cyst is generally a clinical diagnosis based on physical examination!
o Pathophysiology: Bartholin gland or cyst becomes infected
o Usually a polymicrobial:
E. coli (most common), Staphylococcus species, Streptococcus species)
o Clinical findings:
Acute unilateral pain and tender swelling
Pain especially while walking and sitting
Fever ( 20% of cases)
Prompt pain relief with discharge spontaneous rupture of abscess)
o Diagnostics
Pelvic exam: unilateral, tender mass, edema, erythema posterior vaginal introitus
Possible culture
STD testing at the request of the patient
Consider biopsy to rule out malignancy
o Treatment
Incision and drainage followed by irrigation and packing
Fistulization with a Word catheter
Marsupialization - indicated for recurring abscesses
labia minora - cut longitudinally expose cyst or abscess, slit open longitudinally, drained,
everted, sutured to slit edges of labia minora, new opening to allow free drainage
Bartholin gland abscess is usually a clinical diagnosis based on physical examination!

Incubation period: typically 410 days
Clinical features
o Very painful genital ulcers
o Deep, small ( 1020 mm in diameter), well-demarcated lesions with a grayish necrotic base
o Painful inguinal lymphadenopathy
An asymptomatic course is more likely in women.
In contrast to chancre, chancroid is often painful: causative pathogen is Haemophilus du-creyi ("do cry")!
Chancroid is a clinical diagnosis.
Microbiological analysis or culture may confirm the diagnosis - expensive
Gram-stain: gram-negative rods in ulcer exudate
Dark field examination for Treponema pallidum and HSV PCR to rule out primary syphilis
Antibiotic treatment: single dose oral azithromycin or IM ceftriaxone, examine and treat sexual partner(s).
Pelvic examination shows a large, nontender left adnexal

Ultrasonography of the pelvis shows a 10-cm solid left

ovarian mass and a thickened endometrial stripe.

Which of the following is the best next step in

management of this
Endometrial biopsy

Unopposed estrogen possible: endometrial hyperplasia/

carcinoma, postmeno bleeding, thickened endometrium,
breast tenderness
thickened endometrium: Immediate evaluation
endometrial biopsy = gold standard test
Management of suspected ectopic pregnancy
Positive ume hCG,
lowerabdorninal pain,
&Jex vaginal bleeding

Hemoclynam,cal>,t Hemoclynamically
stable unstable

TYUS Immediate surgical

Adnexal mass I tnlrauterine pregnancy I Nondiagnostic

Treat ectopic

Repeal p..hCG level Repeat 13-hCG level
+ in2 days
TYUS in 2days


Endometrial hyperplasia/cancer

Excess estrogen
Risk Chrome anovulation/PCOS
factors Nulhpanty
Earty menarche/late menopause
TamoXJfen use

Clinical Heavy, prolonged, intermenstrual &/or

features postmenopausal bleeding

Evaluation Endometrial biopsy (gold standard)

Pelvic ultrasound (postmenopausal women)

Treatment Hyperplasia: Progestin therapy or hysterectomy

Cancer: Hysterectomy

Patients should be counseled: not known IF steroids prevent scarring+SCC

MORE than once-daily application INCREASES adverse effects:
skin atrophy, discoloration, and striae
Women should be encouraged to nurse the infant every 2 to 3 hours
Preferred empiric therapy methicillin-sensitive S aureus:
dicloxacillin or cephalexin

Risk factors for MRSA:

recent antibiotic therapy, long-term care facility, incarceration
treated w/clindamycln, trlmethoprlm-sulfamethoxazole, or vancomycin
Pelvic ultrasonography shows a 7-cm right ovarian mass with solid components.
thick septations, and a moderate amount of peritoneal fluid. Which of the
following is the most likely explanation for these findings?

Abnormal proliferation of tubal epithelium


Hyperecholc nodules and calcifications are ultrasound features of a mature
cystic teratoma (eg, dermoid cyst), a benign ovarian tumor arising from
ectodermal cells.
Dermoid cysts can have solid components but DO NOT exhibit multiple septae
or cause ascites.
Fat necrosis can mimic breast cancer in its clinical and
presentation because It commonly presents as a fixed mass
with skin or nipple
retraction and gives the appearance of calcifications on
mammography. Ultrasonography can demonstrate a
hyperechoic mass, which often
correlates with a benign etiology. Biopsy is diagnostic and
typically shows fat globules
and foamy histiocytes.

Aromatase deficiency:

In utero placenta cannot make estrogen

=masculinization mother resolve w/deliver

High gestation androgen virilized XX w/:

normal internal genitalia
ambiguous external genitalia

Clitoromegaly when ^androgen IN UTERO

Later life: delay puberty, osteoporosis,

undetectable estrogens, ^gonadotropins,
polycystic ovaries
CASE: woman vulvar lesions, worsened 6 weeks,
medical history genital herpes, 10 yrs ago partner
syphUis, pap ascus-us, neg HPV, smokes
Examination small, papular growths vestibule, fragile,
Condylomata acuminata

Choriocarcinoma suspected:
obtaining quantitative flhCG
helps confirm diagnosis

CT scan of chest = useful for

staging + planning treatment,
may identify nodules WHEN
chest x-ray negative

positive chest x-ray = CT scan


Diagnosis should be confirmed

by B-hCG levels BEFORE
staging + treatment plans
Breast Cyst
ultrasound shows posterior
acoustic enhancement (indicative
of fluid)
no echogenlc debris or solid
components: these features are
consistent with a simple breast

Predisposing factors
Breast cancer in the contralateral breast ; history of ovarian, endometrial, or colorectal cancer
Increased estrogen exposure
High number of total menstrual cycles
Early menarche, late menopause
First full-term pregnancy after age 35 years
Exogenous estrogen intake: hormone replacement therapy after menopause
BRCA1 or BRCA2 gene mutations
Autosomal-dominant inherited gene mutation
Associated with an increased risk for breast cancer ( 70%) and ovarian cancer
BRCA-positive women = 1520 years earlier than women without the mutation
BRCA mutations are found in 510% of all women with breast cancer
Positive family history (e.g. affected first-degree relatives)
+ history of breast conditions (e.g., fibrocystic change, fibroadenoma) with cellular atypia
Previous radiation treatment in childhood
Lifestyle factors: low-fiber, high-fat diet, smoking, alcohol, obesity postmenopausal women
Associated diseases: Li-Fraumeni (Sarcoma, Breast, Leukemia, Adrenal cancer
Autosomal dominant inherited mutation of the p53 tumor suppressor gene
o ^^malignancies early: breast, osteosarcoma, leukemia, lymphoma, brain, adrenocortical
Peutz-Jeghers syndrome
Most breast cancers = adenocarcinomas = ductal tissue (80%) or lobular tissue (20%)
Noninvasive (in situ) carcinomas
o Ductal carcinoma in situ (DCIS) = 25% of all newly diagnosed breast cancers
o Localization: unifocal
o Frequently has a pattern of grouped microcalcifications
o Higher risk of subsequent invasive carcinoma (ipsilateral)
Lobular carcinoma in situ (LCIS)
o 15% of all newly diagnosed breast cancers
o Localization: multifocal
o Microcalcifications are rare
o LOWER risk of subsequent invasive carcinoma (ipsilateral and/or contralateral)
The noninvasive carcinomas are characterized by the absence of stromal invasion!
Invasive carcinomas
o Invasive ductal carcinoma (most common) = 7080% invasive carcinomas
Unilateral localization
Mostly unifocal tumors
More aggressive, early metastases
o Invasive lobular carcinoma = 1015% of all invasive breast carcinomas
Unilateral or bilateral
Frequently multifocal
Less aggressive than ductal carcinoma
Slower metastasis than ductal carcinoma
o Less common subtypes: mucinous (< 5% ), medullary (5%), tubular (12% )
o Inflammatory breast cancer
Patients with breast cancer develop clinical symptoms rather late at advanced tumor stages.
Typical signs may include:
o Changes in breast size and/or shape; asymmetric breasts
o Palpable mass: single, nontender, firm mass, poor margins, upper outer quadrant
o Skin changes: retractions , redness, dimpling, edema, or peau d'orange
o Nipple changes: inversion, blood-tinged discharge
o Axillary lymphadenopathy: firm, ^ nodes (> 1 cm ), fixed to skin/surrounding tissue
o In advanced stages: ulcerations
Paget disease of the breast
o ductal carcinoma (usually adenocarcinoma-in situ or invasive) infiltrates nipple/areola
o Clinical features
Erythematous, scaly, or vesicular rash affecting the nipple and areola
Pruritus, burning sensation, nipple retraction
The lesion eventually ulcerates blood-tinged nipple discharge
o Diagnostics
Nipple scrape cytology: large, round cells, prominent nuclei
Punch or wedge biopsy
Differential diagnosis: mamillary eczema
Surgical treatment, if possible using a breast-conserving procedure
Inflammatory breast cancer
rare advanced, invasive carcinoma
dermal lymphatic invasion cells = common ductal carcinoma, 25% metastatic at time
Clinical features:
o Erythematous, edematous/peau dorange skin plaques over rapid growing mass
o Tenderness, burning
o blood-tinged nipple discharge
o Axillary lymphadenopathy
Differential: mastitis, breast abscess, Paget disease of the breast
Treatment: chemotherapy + radiotherapy + radical mastectomy
Poor prognosis: 5-year survival with treatment = 50% (without treatment: < 5%)
early stage:
o local tumor + <5 cm
o sentinal node + </= 3 cm
local advanced
o large tumor >5 cm
o regional lymph node
o no distant metastasiis
advanced metastatic
o distant metastasis
Women < 30 years w/self-palpated breast lump
o Clinical assessment FIRST
o Ultrasound in women with a high probability of malignancy
o low probability malignancy: reexamine 310 days after onset period
Women > 30 years w/self-palpated breast lump or mammo abnorm screen
o Clinical assessment AND
o Mammography (ultrasound if mammography is inconclusive)
o Age < 35 years
o No family history
o Soft, movable mass
o Size changes with menstruation cycle
o Age > 35 years
o Positive family history
o Firm, rigid mass with irregular borders
o Skin changes
o Axillary adenopathy
o Asymmetry to the contralateral breast, fixation to the skin or chest wall
Radiographic imaging
o does not confirm the diagnosis
o primarily useful for early detection of abnormalities
o Well-defined, circumscribed mass
o Radiolucent ring surrounding the lesion (halo sign)
o Diffuse microcalcification or coarse calcification
o Focal mass or density with poorly defined margins
o Spiculated margins
o Clustered microcalcifications
Breast ultrasound
o Distinguish between solid lesions + benign cysts
o Evaluates axillary, supraclavicular, infraclavicular lymph NODES
o Provides GUIDANCE in interventional procedures
fine needle aspiration, core needle biopsy
Core needle biopsy (CNB)
o confirms diagnosis = preferred test
o can distinguish between noninvasive + invasive carcinoma
o for a suspicious breast mass on ultrasound or mammography.
Fine needle aspiration
o Preferred for assessing mass w/low probability of malignant
o CANNOT distinguish between noninvasive + invasive carcinomas
o if cytology suspicious = core needle biopsy is required to confirm the diagnosis.
Surgical excision
o If CNB is not feasible
o Results of CNB are inconclusive
Workup of diagnosed breast cancer
Receptor testing of biopsy samples - receptors on all breast cells, ^^^ in cancer cells
o Immunohistochemical estrogen and progesterone receptor. + 70% of cases
o FISH or immunohistochemical HER2/neu, + approx. 20% of cases
o Triple negative = approx. 10% of cases, more aggressive, high-grade tumors
Tumor markers
o CA 15-3
o CA 27-29
Axillary node status:
o suspicious nodes workup w/core needle biopsy PRIOR to surgery of breast
Bone metastasis:
o 1st: contrast-enhanced MRI (in patients with localized bone pain or elevated AP)
o 2nd bone scan: if MRI detects metastatic to identify additional occult lesions
Liver metastasis: abdominal CT
Lung metastasis
o CXR or chest CT: usually multiple lesions, mostly unilateral pleural effusion
o Thoracocentesis if pleural effusion: malignant cells in the fluid BLOOD-tinged
Brain metastasis
Axillary lymph node = suggests hematogenic spread has ALREADY OCCURRED!
Noninvasive carcinomas
Macroscopic: firm mass may be visible
Microscopic: Enlarged ducts lined w/atypical epi, intact basal membrane
Microcalcifications are noted occasionally
Two growth patterns
Comedo necrosis: central necrosis, associated w/ ^risk malignancy
Noncomedo: cribriform, papillary, solid
Macroscopic: not visible
Microscopic: lobules filled w/monomorphic cells, intact basal membrane

Lapartomy for
-> cancer resection, staging, inspection
abdominal cavity =definitive treatment when
high suspicion of EOC, particularly with an
acute presentation (ie ascites symptoms)
Pelvic pain in a patient with a
known ovarian mass should be
suspected as ovarian torsion
until proven otherwise
Dermoid cysts HIGHER
rate torsion than other
Twisting around:
o infundibulopelvic
o utero-ovarian
Presents w/:
o unilat pelvic pain
o nausea/vomiting
o fever
o US w/absent blood
o surgical detorsion
o cystectomy
o removal adnexa if
Ruptured cyst mangement: necrosis despite
CBC assess anemia, pregnancy test (exclude ectopic) restoring circulation
pelvic US pelvic free fluid, adnexal mass may be absent in complete rupture
uncomplicated cyst rupture (no fever, hypotension, tachycardia, hemoperitoneum, infection):
o conservatively with analgesics = outpatient.
Ruptured cyst differential:
adnexal torsion
o Both: sudden unilateral pain, ovarian mass is often present
o Torsion: Doppler veloclmetry = enlarged, edematous ovary w/decreased/absent blood flow
o US may show adnexal mass (endometrioma) BUT free fluid is typically NOT present
Tube-ovarian abscess
o fever and leukocytosis
o US: complex multilocular adnexal mass
rather than the simple cyst
cystic teratoma
o US shows an 8-cm left ovarian cyst with calcifications and hyperechoic nodules
Torsion vs ruptured cyst
suspect torsion in teratoma
ruptured cyst: peritoneal signs (pleuritic chest, rigid abdomen, rebound, involuntary guarding)
Simple ovarian and corpus luteum cysts, but typically not dermoid cysts, may rupture
excluding other causes of acute
abdominal pain:
ectopic pregnancy
non~ynecoiogic- appendicitis
wbc = nonspecific

mass with absent Doppler flow

Appendicitis and tubo-ovarian

abscess are infectious causes of
acute abdominal pain but are
unlikely In the absence of fever
and leukocytosis

infundibulopelvic (suspensory ligament of the ovary) and/or

utero-ovarian ligaments
Invasive Carcinoma
Invasive lobular
o Macroscopic: solid
o Microscopic: malignant cells in lobule, monomorphic cells in single file ("Indian file")
o Unilateral or bilateral
Invasive ductal
o Macroscopic: firm tumor, fibrous, grayish-white cut surface
o Microscopic: malignant cells in duct, stromal invasion, microcalcifications
fibrosis in surrounding tissue
o Unilateral
o Well circumscribed tumor
o Poorly differentiated cells with syncytial growth with lymphocytic infiltrates
o Rapid growth
o Well circumscribed tumor
o Extracellular mucus
o Slow growth
o Well-differentiated tubular structures, stromal invasion (radial pattern)
o Slow growth
o Dermal lymphatic invasion
o Angioinvasion
o Rapid growth
o CASE: 42-year-old woman, left breast swe111ng, pain worsened over past month,
weaned child breastfeedlng 2 months ago, month ago mastitis, prescribed antibiotics,
BMI is 46.6, Is 37.6 C (99.7 F), no distress, left breast: diffusely warm, erythematous
DIMPLING, right breast normal
rapid-onset edematous cutaneous thickening
"peau d'orange" superficial dimpling, fine pitting
warm, edematous, erythematous, itchy and painful palpable breast mass
nipple changes = flattening/retraction
axillary lymphadenopathy suggesting metastatic disease
next step mammography + ultrasound, biopsy necessary to confirm
IBC confused w/mastitis, abscess:
common symptoms warmth, pain, + erythema
infection: fever + improves with antibiotic
peau d'orange make an infection unlikely
Infiltrating ductal carcinoma or lobular breast carcinoma differential:
common symtoms: dimpling + breast contour changes
BUT diffuse breast erythema, edema, peau d'orange absent in others
Invasive carcinoma
o Early stage disease
Breast-conserving therapy (BCT): lumpectomy THEN radiation
Contraindications: ^ tumor/breast ratio, multifocal, fixation chest
wall, excision W/O negative margins (> 2 mm), clustered
microcalcifications, involve of skin/nipple, history chest radiation
Surgical margins NEED be tumor free
Consider mastectomy for: unable BCT or REQUESTS aggressive manage
o Intraoperative lymph node evaluation
Sentinel lymph node biopsy: assesses potential lymphatic spread of cancer cells to the
axillary lymph nodes ; indicated for all patients with clinically negative preoperative axillary
lymph nodes
Axillary dissection : for patients with clinically positive preoperative axillary lymph nodes
Adjuvant systemic therapy
Hormone and targeted biologic therapy in all ER/PR+ or HER2+ patients
Chemotherapy in high-risk patients (see table under "Systemic therapy below)
Locally advanced disease
Neoadjuvant systemic therapy + surgical resection (BCT or mastectomy) + axillary lymph
node dissection
Followed by adjuvant systemic therapy radiation therapy
Advanced metastatic disease: systemic treatment followed by palliative surgery and/or
radiation therapy
Gestational breast cancer
Surgery is the treatment of choice (radiation therapy is contraindicated during pregnancy)
Adjuvant chemotherapy only in the second and third trimester.
Noninvasive carcinoma
DCIS: breast-conserving therapy or mastectomy
Mastectomy plus sentinel lymph node biopsy (SNLB) if lumpectomy is not feasible (see
"Contraindications under breast-conserving therapy above)
LCIS: life-long surveillance and chemoprevention with hormone therapy (e.g., tamoxifen)
Indications for prophylactic bilateral mastectomy
A strong family history of breast cancer
Positive for mutations of BRCA 1 or BRCA 2
Patients who do not wish to take chemoprevention/hormone therapy
Systemic therapy
Indications Agents Side effects and contraindications
High-risk patients:
Tumor size > 2 cm
Positive lymph nodes
Aggressive tumor histology
Triple negative breast cancer
Anthracycline and taxane regimen