OPB Flashcards
(85 cards)
Breast cancer: Risk factors, classification, presentation, investigation
Risk factors:
- Age 50+
- History of benign breast disease (cystic disease, papilloma, radial scar)
- Hyperplasia (atypical or proliferative)
- FH
- Previous breast cancer
- Ionising radiation exposure
- Nulliparous
- Obesity
Classification:
By spread
- Early breast cancer (Size <5cm, no axillary lymphadenopathy)
- Locally advanced (Size >5cm, axillary lymphadenopathy
- Metastatic (spread beyond the breast and axilla)
By pathology
- Invasive (e.g. Ductal, lobular
- Non-invasive (DCIS, LCIS)
Presentation:
Symptoms: Lump, nipple discharge or eczema, skin changes/tethering, pain
Identified by screening programme
Investigation
“Triple assessment”:
- Clinical examination
-Imaging (US for <40. Mammogram + US for >40 or suspected cancer cases.)
- Histology (core biopsy first choice)
Staging:
- If early breast disease = CXR, SLNB, US liver, bloods
- If locally advanced= CT chest Bone scan
sentinel lymph node biopsy
Breast cancer: Management
TREATMENT BY DISEASE STAGE
Non-invasive breast cancer in situ i.e. DCIS : Breast conserving surgery +/- post-op radiotherapy
Neoadjuvant therapies
- Older and ER+ve (Aromatase inhibitor)
- Younger and ER -ve (Chemo)
Early invasive Breast cancer = Surgery (usually mastectomy) AND adjuvant therapy
Adjuvant therapy:
- ER+ and pre-menopausal (Goserelin + Tamoxifen)
-ER+ and post-menopausal (Aromatase inhibitor)
- HER+ (Trastuzumab + chemo/radiotherapy)
Metastatic breast cancer: Bisphosphonates (e.g. Weekly IV Zoledronate infusion) for bone mets, radiotherapy or systemic therapies for bone pain palliation, targeted therapies (e.g. Trastuzumab for HER2 +ve)
INDICATIONS FOR AXILLARY CLEARANCE
US of the axilla pre-treatment
1. Normal? SLNB –> Abnormal? Perform axillary clearance as 2nd operation
2.. Abnormal? Do Core biopsy –> Abnormal? Perform axillary clearance at 1st operation
RADIOTHERAPY
@ breast : For ALL WLE patients or women <50 on day for surgery as “boost”
@chest wall : after mastectomy
@ axilla and SCF : After axillary clearance
LONG TERM FOLLOW-UP SCHEDULE
Year 1 and 5 : Mammogram and Clinical examination
Year 10 : Mammogram (and clinical appointment if on endocrine treatment)
Years 2,3,4,6,7,8,9 : Mammogram only
Benign breast diseases
<25
Normal process: Breast development, ductal hyperplasia, lobular hyperplasia
Pathological: Fibroadenoma, juvenile hypertrophy
25-35
Normal process: Lactation, cyclical activity, epithelial turnover
Pathology: Galactocele, papilloma-duct discharge, cyclical mastalgia
35-55
Normal process: Lobular, ductal or stromal hyperplasia. Involution
Pathology: Atypical hyperplasia, macro cysts, duct ectasia, periductal mastitis, sclerosing lesions
Radial scar
What? Localised inflammatory reaction or ischaemia
Risk? 50% association with malignancy
Management? Send for triple assessment
Radial scar, or complex sclerosing lesion, is a rosette-like proliferative breast lesion. It is not related to surgical scarring.
View all
A radial scar is a growth that looks like a scar when the tissue is viewed under a microscope. It has a central core containing benign ducts. Growing out of this core are ducts and lobules that show evidence of unusual changes such as cysts and epithelial hyperplasia (overgrowth of their inner lining).
Gynaecomastia
Cx
Examination
Ix
Mx
Cause:
- Drugs* (e.g. anti-androgen, hormonal drugs, infection medication, cardiac or anti-hypertensives, drugs of abuse, alcohol, cancer/chem drugs, psychoactive drugs)
- Puberty
- Old age
- Tumours (lung, testicular, pituitary)
- Liver disease
Examination
- Breast tissue: Feels rubbery and firm. Cancer would be hard/firm. Tissue located concentrically around areola. Cancer tends to locate more peripherally
- Liver exam
- Spleen exam
- Axillary lymph node examination
Investigations
If patient is 18-60 years with no obvious cause AND significant breast tissue –> Bloods (FBC, LFTs, Testosterone, LH, FSH, beta HCG, AFP, prolactin, U+Es)
If patient is >40 years –> Mammogram
If patient has discrete lesion –> US and core biopsy
If patient has abnormalities detected on examination –> Consider CXR and testicular exam
Management:
1st line: Reassure and address any underlying problem. Will resolve in a couple months
2nd line: 20mg OD tamoxifen for 6 months (consider aromatase inhibitor for older men)
Mastitis Classification Features Referral criteria Tx
CLASSIFCTION
Lactating: Due to staph aureus infection
Periductal mastitis: Peri areolar, smoking
- Risk of mammary duct fistula
Skin lesions: Epidermoid cysts, hydradinitis
FEATURES
Timing: Rapid
On examination:
• A red, swollen area on the breast (feels hot and tender on touch)
• Area of hardness on the breast
• A burning pain (continuous or during breastfeeding)
• Nipple discharge (white or blood stained)
• Flu-like symptoms
REFERRAL CRITERIA:
• Mastitis or breast inflammation unresponsive to one course of antibiotics
• Abscess or breast inflammation in patient over 35yrs
TREATMENT
1st line:
- Abscess present? Drain using LA.
- Antibiotics (neonatal/ lactating/ skin-associated –> Flucloxacillin. Non-lactating –> Co-amoxiclav)
Duct ectasia
What? An aberration of development and involution
Who? Women >50
Features: Nipple discharge (Cheesy /white), slit-like nipple retraction, doughy palpable mass
Management: Either conservative or surgical (Total duct excision)
Duct ectasia, also known as mammary duct ectasia, is a benign (non-cancerous) breast condition that occurs when a milk duct in the breast widens and its walls thicken. This can cause the duct to become blocked and lead to fluid build-up. It’s more common in women who are getting close to menopause
Duct papilloma
What? Development in lumen of mammary ducts
Age 35-55
Presentation? Bloody discharge
Risk? Rarely malignant
Phyllodes Tumour
What? Hypercellular stroma with atypia
Age? 35-50 years
Progression? Varied. May locally recur and metastasise
Treatment: Wide local excision (WLE) with clear margin or normal breast tissue
Hydradinitis Suppuritiva
What? Chronic inflammation of the axillary apocrine sweat glands
Presentation? Recurrent infections, abscesses, scar formation
Treatment: Antibiotics, drainage of abscesses, excision of the affected area
Mondor’s Disease
What? Self limiting, thrombophlebitis of the superficial vein on the breast and axilla
Presentation: Redness, pain and cord like thickening of the vein
Treatment: NSAIDs
Risk: Rare association with underlying malignancy
Breast screening
Who? All women aged 50-70. Women above 70 can arrange 3 yearly scan through their screening service
When? 3 yearly interval
What? Mammography, 2 views (craniocaudal “CC” and mediolateral oblique “MLO”). All films are reported twice
Follow-up:
If abnormal result, patient recalled for:
- Repeat mammographic views, including magnification
- Clinical examination
- US
- FNA/Core biopsy
Malignant hypercalcaemia
DDx for hypercalcaemia:
- Severe hypercalcaemia
- Primary or tertiary hyperparathyroidism
- Thyrotoxicosis
- Bone mets
- Advanced solid tumours (lung, breast, multiple myeloma)
- Thiazide diuretics
- Vit D excess
- Sarcoid
Presentation:
- Bone pain /fracture
- Polyuria + polydipsia
- Abdo pain + constipation
- Renal colic
- Confusion / Coma
- Fatigue
Investigations
Bloods: cCa, PO4, PTH, U+Es, Mg,
ECG: PR interval prolonged? QRS wide?
Management:
1ST - HYDRATION
If asymptomatic and cCa<3 –> Oral fluids, monitor and mobile
If symptomatic and cCa >3 –> 3L of 0.9% NaCl in 24hrs. Correct K and Mg as needed. Aim for UO for 150ml/hr. Once rehydrated, switch from thiazide diuretic to furosemide
2ND - BISPHOSPHONATES
If cCa still >3 after rehydration, then 4mg of zolandronate in 50ml salone or 5% dextrose over 15 mins. Monitor renal function, for hypocalcaema, PO4 and K. IF eGRF is <30 then use pamidronate.
3RD - MEDICATION REVEIW
Esp those medications that effect renal function e.g. NSAIDs, ACEIs, Diuretics
4TH - FOLLOW UP
Reassess U+Es 3-4 days later. If still not correct, consider rescue therapy.
Dialysis is an option if adequate hydration cannot be achieve due to renal or cardiac failure.
SVCO
Cause:
- Intraluminal thrombus (e.g. DVT, central line, tumour in the vessel)
- Extrinsic compression
- Invasions
Presentation:
Onset = Insidious
Symptoms: Collateral vessel development, face and neck swelling, Dizziness/lethargy/syncope, conjunctical suffusion, SoB, headache, epistaxis
Signs: Non-pulsatile raised JVP, venous collaterals, arm oedema
Investigation
Non-acute to determine cause: CT, CXR, venogram and coag screen
If extrinsic compression, histology of mass using CT-guided FNA or biopsy or bronchoscopy
Management:
Immediate = ABCDE (including O2 and sit patient forwards)
Clot:
- Local thrombolysis
- Anti-coag → LMWH
- Line removal
Extrinsic compression
- ABC→ sit upright, O2
- Steroids → dexamethasone
- SVC stent insertion
- Treat underlying tumour with with Chemo (SCLC, lymphoma) or Radiotherapy (solid tumour)
Malignant pericardial efffusion
Cause: *Lung cancer. Also breast cancer, lymphoma, oesophageal cancer, melanoma, leukaemia
Presentation
Acute: Rapid onset of dyspnoea, chest pain
Subacute: Asymptomatic, dyspnoea, chest discomfort, easily fatiguable
Investigations:
ECG: Low voltage QRS
US: Tamponade present?
Management. Depends if tamponade present..
- With tamponade: URGENT pericardial drainage via percutaneous pericardiocentesis
- Without tamponade: Pericardial fluid sampling / biopsy if needed. REFERRAL early to palliative care services. Prevention of reaccumulation either with prolonged catheter drainage OR create pericardial window
Neutropenic Sepsis
What?
Neutrophil count < 0.5 x 10^9 in a pt who is having anticancer treatment and has one of:
- temp higher than 37.5℃/ less than 36.5
- other signs/symptoms consistent w/ clinically significant sepsis
Cause:
Most at risk 7-21 days post-chemotherapy
Esp for patients receiving highly myelosuppressive therapies e.g. leukaemia or lymphoma patients
Scoring for risk of complications
MASCC 0-26 (High = low risk)
MASCC <21 or NEWS >=6 = “High risk”
MASCC >= 21 or NEW <6 = Standard risk
Investigations
- Sepsis screen (Urine culture, blood culture, line culture, LP if indicated)
- Bloods
- Imaging (CXR, AXR, CT?)
- Urine dip
- Viral throat swab
Treatment
Immediate with 1 hour… (don’t want for FBC/culture)
- For HIGH risk patients = IV Tazocin AND gentamicin within 1 hour
- For STANDARD risk patients = IV Tazocin + specific cover if appropriate (e.g. Vancomycin for MRSA, Clarithromycin for atypical pneumonia)
Oral stepdown…
- Oral co-amoxiclav and ciprofloxacin
Granulocyte-Colony Stimulating Factor (GCSF) Not routinely used Indications: • Profound neutropenia (<0.1) • Prolonged neutropenia (>10 days) • Pneumonia • Hypotension • Multi-organ dysfunction • Uncontrolled primary disease • Invasive fungal infections • Age >65 • Hospital inpatient at time of developing fever
Tumour Lysis Syndrome
What?
The rapid release for tumour cell contents into the blood after treatment.
Pathophysiology Tumour cells release: 1. Potassium 2. Phosphorus 3. Uric acid Phosphorus then sops up Ca, causing hypocalcaemia
Cause:
Tumour feature: High burden, within rapidly dividing cells (e.g. high grade lymphoma, acute leukaemia), tumours v responsive to treatment
Patient features: Dehydrated, pre-existing kidney dysfunction
Presentation:
- Cardiac arrhythmias/ palpitations and sudden death
- Muscle cramps
- Hallucinations, seizures, numbness
- AKI features (dark urine, flank pain, reduced UO)
- Fatigue, reduced appetite
- Nausea +/- vomiting
Clinical diagnosis
- Increased serum creatinine
- Cardiac arrhymthia or sudden death
- Seizure
Management Acute: • Calcium gluconate • Fluid resuscitation • Rasburicase (uric acid --> allantoin) • Phosphate binder (e.g. al hydroxide) Consider: Renal dialysis, sodium bicarbonate
Non-acute:
LOW RISK - Regular monitoring. Oral allopurinol
IMMEDIATE RISK e.g. large cell lymphoma, ALL, AML, CLL - Prechemo IV hydration + phosphate binder
+ allopurinol / rasburicase
HIGH RISK e.g. Burkitt’s lymphoma -
Prechemo IV hydration + phosphate binder + rasburicase + Loop diuretic
Malignancy spinal cord compression
Cause: Tumour growth, tumour mets (e.g. lung, breast, prostate and multiple myeloma) or vertebrae collapse
Presentation:
Symptoms: Neuropathic pain (“radicular and band-like”, sharp and shooting), paraparesis, paraplegia, paraesthesia, bladder/bowel disturbance
Progression: Pain then weakness then sensory/autonomic symptoms
Depends on level of lesion: above L1 → UMN signs in legs, below L1 → LMN in legs
Ix: MRI whole spine within 24hrs. If no history of cancer, obtain tissue biopsy
Scoring: Tokuhashi score to aid management decision.
Treatment:
1st line: Dex 16mg Oral / IV AND PPI. Radiotherapy asap
2nd line: Options…
- Surgery (if single area of compression from solid tumour? Consider circumferential decompression then radiotherapy)
- Chemotherapy (for lymphoma, teratoma, SCLC)
- Hormone therapy (for met prostate cancer)
Monitoring:
- Glucose (for steroid induced diabetes)
- Analgesia
- Thromboprophylaxis
- Physiotherapy
- Spine stability
Aromatase Inhibitor: Letrozole
MoA: Inhibitors action of aromatase which normally catalyses the breakdown of androgens into oestrogen. Useful for ER+ve cancers as it decreases the amount of circulating oestrogen
Indication: 1st line for ER+ve breast cancer in post-menopausal women. Can be used as neo-adjuvant of adjuvant theraapy
Cautions:
- If creatinine clearance is <10ml/min
- If Susceptibility to osteoporosis
- If severe hepatic impairment
- Use contraception until fully postmenopausal
Contra-indications:
- Pre-menopausal
- Avoid if Breastfeeding or pregnant
Main side effects:
- Arthralgia
- Alopecia
- Osteoporosis (require BMD before and during treatment)
- Hot flushes
Trastuzumab (Herceptin)
MoA: Targets tumours positive for Human Epithelial growth factor Receptor 2 (HER2)
Indications:
- Breast cancer HER2+ve: Either early or metastatic
- Gastric cancer HER2+ve: Metastatic
Route: IV infusion or Sc injection
Contra-indications
- Dyspnoea at rest
- Cardiac disease (e.g. CAH, HTN history, uncontrolled arrhythmias, symptomatic heart failure_
Drug interactions
- Live vaccines
- Risk of cardiotoxicity with other cancer drugs e.g. Anthracyclines, pixanthrone and mitoxanthrone
SE
- Common: Flue-like symptoms and diarrhoea
- Risk of congestive heart failure
- Pulmonary events e.g. interstitial lung dsiease
- Hypersensitivity reaction
Monitoring
- Cardiac function before and during treatment
Rituximab
Class/MoA: Monoclonal antibody against B-lymphocytes by binding to CD20 on cell surface. Therefore this is an immunotherapy chemo drug
Indications: Haematological cancers (Stage III-IV follicular lymphoma, diffuse large B-cell NHL, CLL and maintenance therapy for NHL)
Route:
IV - NHL and CLL.
SC - CLL
CI
- Severe HF
- Infection
- Live vaccines
- Uncontrolled heart disease
SE
Myelosuppression**
Monitoring
Contraception to be taken during and post treatment
Look out for cytokine release syndrome
Capecitabine
MoA: Anti-metabolite that converts to Fluorouracil in tumour cells and then prevents de novo DNA synthesis
Indications:
- Rectal carcinoma (with radiotherapy)
- Stage III colorectal cancer (adjuvant post-surgery)
- Breast cancer (2nd line with docetaxel)
- Gastric cancer (with platinum based therapy)
Contra-indications:
- G6PD inactivity
- Pregnant or breastfeeding
- Fluorouracil hypersensitivity
- Severe hepatic or renal impairment
SE
- Common: GI disorder, anorexia, diarrhoea, hand-foot syndrome, fatigue
- Rare but life threatening: Steven johnson syndrome, cardiotoxicity, toxic epidermal necrosis, infertility
Dosage
Cycle of oral BD
*Risk of incorrect dosage
Monitoring
- Plasma Ca levels
- Eye disorders
- Sever skin reactions
Goserelin
Moa / Class: GnRH analogue –> Inhibition of pituitary secretion of testosterone and oestradiol after 21 days
Route: SC every 28 days
Indications:
- Prostate cancer (locally advanced or metastatic)
- Breast cancers
Contra-indications:
- Breastfeeding
- Pregnancy
- Undiagnosed vaginal bleeding
Monitoring:
- Depression
- QT prolongation
- **Men in the 1st month: Worsened glucose tolerance, ureteric obstruction, spinal cord compression) ** GIVE FLUTAMIDE (Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.)
SE:
- Hot flushes
- Sweating
- Gynaecomastia
- Increased HF risk
- SC site injury
Imatinib
MoA/Class: TKI (prevents cell proliferation by binding to BCR-ABL active site)
Route: Oral
Indications: CML, CLL or GIST (GI stromal tumour)
Contra-indications: Pregnancy, breastfeeding, HBV (risk of reactivation)
SE:
Generally well-tolerated BUT N/V, rash, oedema, diarrhoea and myelosuppression.
Rare but risk of infertility, tumour lysis syndrome and pericardial effusion
Monitoring:
For: GI bleeding, fluid retention
Regular FBC and LFTs
