OPB Flashcards
(370 cards)
1
Q
what age are fibroadenomas seen in
A
20-30
2
Q
what are are cyst seen in
A
30-40
3
Q
main 2 causes of breast infection
A
smoking
lactation
4
Q
what is slit like nipple inversion signify
A
usually benign
often nipple can be fully everted with manipulation
5
Q
presentation of nipple eczema
A
often starts on the areola and spreads
red scaly nipples
6
Q
paget’s disease presentation
A
-starts on the nipple itself
does not completely resolve with topical steroids
older women
can be assoc. to pre-invasive cancer so take a biopsy if in doubt
7
Q
ages and benign breast disease presentation 20-30
A
fibroadenoma
juvenile hypertrophy
8
Q
25-35 breast benign disease
A
cyclical mastalgia
galactocele
papilloma duct discharge
9
Q
> 40 benign breast disease
A
cysts
periductal mastitis
sclerosing lesions, hyperplasia, atypia
duct ectasia
10
Q
pathology of breast cyst
A
fluid filled and benign
usually pre-menopausal
distended involuted lobules
11
Q
presentation of breast cyst
A
- mobile well defined lumps
- firm and rounded
- not fixed
- not assoc. with skin changes
- most are impalpable, asymptoamtic and found incidentally
- can be painful
- can appear rapidly
12
Q
diagnosis of breast cyst
A
USS/ mammogram
13
Q
management of first breast cyst
A
-refer for exclusion of malignancy -urgently if >30
14
Q
management of past hx of breast cyst -
A
aspiration
15
Q
which signs on breast cyst aspiration need referring on
A
- blood stained
- cyst refills
- residual lump after aspiration / solid areas (intra-cystic papillary carcinoma?)
16
Q
what is a galactocele
A
milk containing cyst which arise during pregnancy
17
Q
management of a new lump in pregnancy
A
refer
18
Q
what is a radical scar/ complex sclerosing lesion on the breast
A
- scar arising in breast but without any previous trauma or surgery
- cause unknown- inflammation
19
Q
management of breast radical scar
A
-1 in 5 have cancer
-need to refer
often excision
20
Q
assoc. of breast radical scar
A
atypical duct hyperplasia
21
Q
risks of papilloma
A
-can cause breast cancer
22
Q
what is a breast papilloma
A
- wart like lump that forms in the duct if intraductal
- develops inside the lumen
23
Q
presentation of breast papilloma
A
- wart like lump in the duct
- nipple discharge which can be blood stained
24
Q
management of breast papilloma
A
refer for excision
25
fibroadenoma pathology
- derived from lobules
- aberration of normal breast development
- under hormonal control -can increase in pregnancy
- benign breast tumour--> formed by proliferation of both stromal and epithelial components of the breast
26
classification of fibroadenoma
-common
giant >5cm
juvenile- teenage girls
27
presentation of fibroadenomas
-mobile well defined lump
-non tender
-highly mobile
-firm or rubbery
smooth mobile
28
management of fibroadenoma
- refer for confirmation of diagnosis
- urgent referral if >30, fhx or suspcious feature
- triple assessment need core biopsy to confirm not a phyllodes tumour
- remove if growing/ patient wish
- excise if >3cm
29
diff dx of fibroadenoma
phyllodes tumour so need core biopsy
30
prognosis of fibroadenoma
1/3 regress alone
1/3 stay same
1/3 grow
vv rare to become cancerous
31
cause of fat necrosis of breast
- usually hx of injury or bruising
- as bruising settles, scarring results in a firm lump of the breast
- most common in large breast
32
management of fat necrosis of breast
- refer for breast triple assessment
- always urgent referral
- once dx confirmed no treatment needed
33
mondor's disease of breast is...
inflammation of the superficial veins of the breast
| benign thrombophlebitis of vein and axilla
34
presentation of mondor's disease
- red pain and cord like thickening of vein
| - self limiting
35
management of Mondor's disease
- triple assesment - referral
- rarely assoc. to malignancy
-treatment NSAID
36
Hydranitis suppurativa what is it
-young patients
| acne on arm pits
37
cause of hydranitis suppurativa
-chronic inflammation of axillary apocrine sweat glands
38
management of hydranitis suppurativa
antibiotics, drain abscesses, excision
39
complications of hydranitis suppurativa
recurrent infection
abscess
scar formation
40
what age does hydranitis suppurativa tend to stop
35
41
congenital abnormalities of the breast
-third nipple
accessory axillary breast tissue- as breast tissue develops in the axilla and moves across- so if left behind
abscence or hypoplasia of the breast- symmetricla or asymmetrical can use implants
inverted nipples
absence of chest wall
gigantomastia
42
what is poland syndrome
absence of chest wall
dont develop pectoralis major and breast and chest wall
reconstructive procedure
43
what is gigantomastia
breast tissue becomes very inflamed red and grows rapidly
44
what is duct ectasia
-abberation of development and involution
-occurs when a milk duct beneath the nipple widens, the duct walls thicken
duct fills with fluid and becomes blocked
45
who gets duct ectasia
often >50 around menopause
46
symptoms of duct ectasia
- nipple discharge- often green
- retraction
- inverted nipples
- doughy palpable mass
- discharge cheesy/ white
- slit like nipple retraction
47
management of duct ectasia
-refer for confirmation of dx
conservative management or
surgical with excision of total duct
48
what is phyllodes tumour
- hypercellular stroma with atypia
- large and fast growing
- arise from periductal stromal cells of the breast
49
differentiating phyllodes and fibroadenomas
phyllodes usually larger and older age group
| 30-50 yrs
50
behaviour of phyllodes tumour
-varies
benign 70%, malignant 5% or borderline 25%
-malignant potential
-can have an infiltrative margin especially in aggressive forms
51
management of phyllodes tumour
need referral for triple assessment
| wide local excision with clear margin of normal breast tissue
52
mastitis presentation
- develops quickly
- red swollen area on breast that may feel hot and painful to touch
- area of hardness on the breast
- burning pain- continuous or with breastfeeding
- nipple discharge- white and blood stained
- feeling generally unwell- aches, fever, shiver, tired
53
when to refer mastitis
- if not settling after one course of antibiotics
- refer for abscess
- breast inflammation in >35 even if settling
54
management of mastitis
-antibiotics
| drain abscess under la
55
lactational infection cause
- usually in early weeks post-partum
| - poor latch, nipple trauma, milk stasis
56
management of lactational infection
- treat early with antibiotics- flucoxacillin
| - continue feeding as avoid milk stasis
57
cause of non-lactational infection
-mostly due to smoking
periductal infection
often chronic and difficult to treat
58
what is peri-ductal mastitis
-inflammation of ducts below nipples
59
who gets peri-ductal mastitis
smokers
60
presentation of peri-ductal mastitis
-repeated infection +/- abscess formation at edge of areola and can get fistula
61
management of peri-ductal mastitis
```
-co-amoxicillin first line
smoking cessation
drain abscess when they occur
can evenutally over yrs burn out
-mostly non -operative approach
```
62
sebaceous cyst on breast management
- treat as elsewhere
- drain if abscess
- consider formal excision of cyst wall when acute resolves
63
main cause of breast abscess in lactation
staph aureus
64
causes of breast absceses
lactation infection
periductal mastitis-peri-areolar
epidermoid cyst, hidraenitis
65
management of breast abscess
- refer for surgical assessment
- will aspirate with large needle and drain
- flucox or erythromycin for lactation
-non: lactating: co-amox, or erythromycin and metronidazole
66
complication of peri-ductal mastitis
mammary duct fistula
67
management of mammary duct fistula
-excision of fistula and total duct excision
68
A 49-year-old woman presents with a 2 week history of left nipple itching. There has been no discharge from the nipple and there is no personal or family history of breast disease. The patient's history is remarkable for asthma and eczema.
On examination, the left nipple and surrounding areola are reddened and the skin appears thickened. Examination of both breasts is otherwise unremarkable.
paget's disease as redenning and thickening of nipple and areola
69
differentiating eczema and pagets of nipple
-pagets starts on nipple and later spreads to areola
(vice versa in eczema)
- paget's thicken and red nipple
- need to biopsy as risk of underlying pre-invasive cancer
70
paget's disease management
refer urgently
71
A 52-year-old lady presents to her general practitioner. She is concerned about a lump which she has noticed on her left breast associated with a green nipple discharge. On examination, she has a tender lump on her left breast next to her areola. It is not discoloured or hot to touch. Which one of the following conditions would be most likely to cause this presentation?
duct ectasia
also get involution
menopausal
72
paget's of nipple is assoc. too
invasive ductal carcinoma
73
fibroadenosis pressentation
-most common middle age
lumpy breasts which can be painful
symptoms may worsen prior to mensturation
74
A 21-year-old female notices a bloody discharge from the nipple. She is otherwise well. On examination there are no discrete lesions to feel and mammography shows dense breast tissue but no mass lesion.
intraductal papilloma
75
commonest cause of blood nipple discharge in young women
intraductal papilloma
76
A 18-year-old female notices a non tender mobile breast lump. Clinically there is a smooth lump which is not tethered to the skin.
fibroadenoma
77
Females < 30 years with a non-tender, discrete and mobile lump =
fibroadenoma
78
A 30 year old lady presents with a 3 week history of worsening erythema over her left breast. She is not breastfeeding and feels otherwise well. She says that it is not painful but is concerned as it has not resolved. On examination the breast is swollen with marked erythema but no discharge, no nipple changes and no mass palpable. Her vitals are within normal range and she is apyrexial. Results of blood tests are outlined below.
White cell count 6x10^9/L
C-reactive protein 4 mg/L
CA 15-3 level 57 Units/ml (normal range <30 Units/ml)
What is the most likely diagnosis?
inflammatory breast cancer
as raised Ca marker
and also mastitis would have fever or elevated WCC
79
inidcations for antibiotics for lactational mastitis
1st line= continue breast feeding
give antibiotics if
1. culture positive
2. nipple fissure present
3. systemic symptoms
4. no improvement 12-24hrs of effective milk removal
80
. A 48-year-old lady presents with discomfort in the right breast. On examination she has a discrete soft fluctuant area in the upper outer quadrant of her right breast. A mammogram is performed and a 'halo sign' is seen by the radiologist.
halo sign= cyst
81
You are working in general practice. An 87-year-old lady complains that her right nipple is exquisitely itchy. On examination, you note that the nipple is erythematous and there is some blood-stained discharge on the inside of her bra.
paget's disease
82
A 52-year-old lady presents with an episode of nipple discharge. It is usually clear in nature. On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood. Imaging and examination shows no obvious mass lesion.
intraductal papilloma
as no mass or lesion seen
and can arise from a single duct
83
what does a triple assessment involve
- clinical hx and exam
- imaging- USS or mammogram
- pathology- FNA, core biopsy
84
breast awareness 5 point code
1. know what is normal for you
2. know what changes to look and feel for you
3. look and feel
4. report any changes to GP without delay
5. attend for routine breast screening if >50
85
lump features that require an urgent referral 7
1. any new discrete hard lump in patients over 30
2. any age with phx of breast cancer presenting with a further lump or suspcisious symptoms
3. asymmetrical nodularity that persists after period in patients over 35
4. aged >35 with discrete lump that persists after next period or presents after menopause
5. unilateral isolated axillary lymph node in women persisting at review after 2-3 weeks
6. recurrent lump at site of previously aspirated cyst
7. aged <35yrs with a lump that enlarges or is fixed/ hard in whom there are other reasons for concerns such as hx
86
nipple changes that require an urgent referral 3
1. unilateral eczematous skin or nipple changes that don't respond to topical treatment
2. nipple distortion of recent onset eg retraction
3. spontaneous unilateral blood nipple discharge
87
skin changes that require an urgent referral
1. skin tethering or dimpling
2. fixation
3. ulceration or peau d'orange
88
non urgent referral for breast cancer
- if <35 yrs with a lump that has no suspicious features and not enlarging
2. persistnet unilateral spontaneous discharge- not blood stained
3. breast pain and no palpable abnormality
89
where do most breast cancer arise from
terminal duct lobular unit
90
breast symptoms
```
lump
nipple discharge retraction
skin changes
abscess/ infection
pain
gynaecomastia
```
91
breast lump causes
```
breast cancer
fibroadenoma
cyst
duct ectasia
fat necrosis
phyllodes tumour
```
92
signs of malignancy of breast on mammogram
```
high density lesion
microcalcification
irregular margin
distortion
asymmetry
lymphadenopathy
```
93
signs of malignancy on USS
```
irregualr margin
posterior acoustic shadowing
distorition
heterogenous echo tecture
echogenic halo
TALLER THAN WIDE
vascularity
```
94
signs of fibroadenoma on mamogram
wider than taller- suggest more benign
95
indications for MRI
good for implants, occult lesions and extent of disease
96
indications for choosing FNA over core biopsy
core biopsy main one done but
USE FNA if
- if core biopsy is not technically possible with location?
- cyst
- lymph node assessment
97
when is core biopsy not indicated for fibroadenoma
if <22 and lesion <2cm with unequivocal radiological appearance of fibroadnoma- dont need biopsy but should re-scan after 6 months check not growing
98
breast pain 2 causes
1. cyclical breast pain-true breast pain usually bilateral
| 2. MSK usually unilateral
99
mastalgia causes
```
physiological
duct ectaasia
breast cancer
sclerosing adenosis
mastitis
abscess
```
100
mild to moderate cyclical breast pain management
- diet reduce sat fats and caffeine
- support- wear soft support bra at night
- NSAID
- change or stop OTC
101
severe cyclical breast pain management
for 7 days for >6 months and interferes with lifestyle
- trial mild to moderate management first for 3 months and then referral if no response
- tamoxifen can be given
102
non cyclical breast pain means
continuous or intermittent pain but not related to menstrual cycle
103
causes of non cyclical brest pain
- well localised= ill fitting bras, cyst, abscess, cancer
| - more generalised= referred pain eg nerve root
104
bilateral nipple discharge causes
central
| -pituitary adenoma- galactorrhoea
105
causes of nipple discharge
-pregnancy
-duct ectasia
inflammation
papilloma
DCIS/ invasive cancer
endocrine
mamary fistulas
joggers nipple
medications
106
drugs that cause nipple discharge
haloperidol
methyldopa
phenothiazines
107
red flags nipple discharge
unilateral
blood stained
single duct (except papilloma-although can sometimes)
108
management of nipple discharge
```
triple assessment
explain and re-assure
microdohectomy
total duct excision
specific intervention
```
109
when to refer for nipple discharge
- unilateral-urgent
- bloody-urgent
- >50 and pathological cause suspected= unilateral, single duct, spontaneous, red brown or black, profuse and watery
110
gynaecomastia cause
- age- puberty (self-limiting), old age
- liver disease
- testicular problems
- drugs- alcohol, smoking, steroids, diuretics, omeprazole, allopurinol, digoxin
-tumours- pituitary lung and testicle
111
presentation of gynaecomastia
benign enlargement of the male breast resulting from the glandular component of the breast
- rubbery or firm mass
- ususally bilateral
112
inx for gynaecomastia
- 18 to 60 do a blood test if no obvious cause
- >40 mamogram
- <40 USS
- lesions FNA or core biopsy
- testicular USS or CXR if suggestion of other cancers
113
management gynaecomastia
- treat underlying cause
- reassurance of innocent nature of condition and resolves spontaneously
- endocrine refer to endocrinologist
- no inx for puberty gynaecomastia
114
medical treatment for gynaecomastia
for idiopathic or residual gynaecomastia
- tamoxifen if justified for 6 months
- aromatase inhibitors older men
- surgery is rare
115
when to refer breast nodularity
if asymmetrical and older than 30 or fhx of breast cancer then refer
if asymmetrical <30 and no fhx review in 6 weeks and if still present then refer
116
when to refer nipple eczema
if no response to topical treatment
117
choice of breast imaging >40
use mammogram
| need two views
118
two views needed on mammogram
mediolateral oblique and
| cranial caudal projection
119
choice of breast imaging <40
USS if focal breast problem- 1st line
| adjunct mammography where malignancy is suspected
120
choice of breast imaging in male <40
USS
121
choice of breast imaging in males >40
mammography
122
imaging choice if implants
mammography >40 plus USS
uss <40
may also need MRI to exclude malignancy or implant rupture
123
USS indications
palpable lump
not in pain
-examine axillary lymph nodes
useful for
- core biopsy or aspiration
- detects solid vs fluid filled
124
why is USS not used for breast screening programs
very user dependent
| should only be used as a targeted inx not for whole breast screening
125
implant rupture imaging
USS or MRI
126
mammography indications
breast abnormalities >40
national screening program
early screening if fhx
127
routine referral breast
Lump in breast that isn't caused by anything else and under 30
Lumpiness in breast that doesn't go away after period/ 2 or 3 weeks and you are under 35
Persistent nipple discharge that stains outer clothes
Breast pain lasting for over 3 months and you are post menopausal
Severe breast pain that is affecting your daily life or sleep at night and trialled rx for 3 months
128
urgent breast referral
Over 30 with a new breast lump
Swollen lymph node in armpit that doesn’t go away after 2 or 3 weeks
Over 35 and with lumpiness in breast that doesn't go away after period/ 2 or 3 weeks
Recurrent cyst in breast
Nipple changes such as pulling inward, a bloodstained discharge, or an eczema-type rash (that doesn't respond to steroid treatment after at least 2 weeks)
Skin changes, such as tightening, redness and soreness, or looking like orange peel
Inflammation of the breast that doesn't respond to antibiotics
129
why is mammography used for breast screening
because it can also detect micro-calcification in situ disease
130
what is tomosynthesis
3D mammography
131
additional information of core biopsy
tells you about grade, ER PR and HER2 status
132
additional information of core biopsy
tells you about grade, ER PR and HER2 status
133
breast cancer epidemiology
most common cancer in UK women
| second commonest overall
134
lifetime risk of breast cancer
1 in 8
135
worrying signs for breast cancer
- hx of new lump
- does not change size with periods
- nipple discharge that is spontaneous and blood stained
- axillary lymphadenopathy
- weight loss, fatigue
- fixed nipple retraction
- orange d peau
- ulceration
136
risk factors for breast cancer
-most after >65 (>50)
-oestrogen exposure-
early menarche and late menopause (>55)
age at first pregnnacy (late age and nulliparity)
HRT and contraception use
use of unopposed oestrogen
use of oral contraceptives for >4 yrs before pregnnacy
diet weight and alcohol
fhx and SES
specific benign abnormalities
-radical scar and papilloma
benign breast disease
- espeically cystic disease
- previous breast surgery for severe atypical hyperplasia
proliferative types of hyperplasia
exposure to ionising radiation
later first childbirth
hormone therapy
nulliparity
obesity BMI >30
not breastfeeding?
137
diet and breast cancer
high in fat
low in beta carotene
folate vit a and c low
138
what does a fhx of breast cancer mean
- >1 affected relative on same side of family especially <50
- bilateral breast disease in close family member
- male breast cancer in close family member
- breast and ovarian cancer in close relatives on same side of family
139
genes invovled in breast cancer
```
5% are BRCA
BRCA1
BRCA2
PTEN COWDEN
MSH1 or MSH2 in HNPCC
p53 syndromes
```
140
penetrance and assoc. cancers of BRCA 1
80% penetrance
| ovarian, colon, prostate
141
BRCA2 penetrance and assoc. cancer
50% penetrance
male relatives
also ovarian cancer
142
management of BRCA breast cancer
bilateral mastectomy
MRI screening annually
prevent Tamoxifen in ER positive fhx
143
breast screening procedure
-all women 50 to 69 get invited every 3 years for a mammogram
but can drop in and get a mammogram done whenever at local centre
144
breast screening for moderate risk
begins with yearly mammography at 40
145
breast screening for high risk
begins with yearly mammography at 30
146
breast screening program for BRCA 1 or 2
yearly MRI and mammography from age 30
147
breast screening program for Tp53 faulty gene
yearly MRI from 20
148
breast cancer pathology
- commoner in the left breast
| - 50% in upper outer quadrant
149
most common breast cancer type
ductal carcinoma
150
breast carcinoma pathological types
- invasive = ductal, lobular
- non-invasive= DCIS, LCIS
- mixed lobular and ductal
- sarcoma
- medullary, mucinous, tubular, micropapillary, metaplastic, inflammatory, paget
- phyllodes and angiosarcoma
151
angiosarcoma breast cancer pathology
-originates from blood vessels of lymphatic and can occur as primary or secondary in patients who have been previously treated by radiotherapy for breast cancer
rare
152
lobular in situ neoplasia
- often an incidental finding
- risk factor for recurrence
- doesn't impact Rx decision
- need a guided excision to exclude DCIS or invasive disease
153
ductal carcinoma in situ % of breast cancers
90%
154
definition of ductal carcinoma in situ
-abnormal proliferation of cells within the mammary ducts which does NOT spread beyond the basement membrane
aka no invasion
doesnt spread elsewhere
progression to invasive over months to decades
155
inx for DCIS
-can be seen on mammography as microcalcification
impalpable so usually only seen on screening
core biopsy
156
management of DCIS
surgical: all diseased tissue must be excised with clear histological margins
- radiotherapy in high grade DCIS
157
invasive ductal carcinoma % of breast cancer
75%
158
how does invasive cancer spread
tumour invades through the lymphatics
159
signs of locally advanced and metastatic breast cancer
peau d orange
skin inflammation
skin involvement
chest wall involvement
rare
systemic treatment prior to surgery
160
inflammatory breast cancer presentation
need to always consider as a cause of mastitis
| so if mastitis doesnt improve with antibitiocs then refer urgently
161
management of inflammatory breast cancer
-aggressive cancer
-triple assessment
chemo
surgical
radiotherapy
162
receptors for breast cancer
ER- estrogen receptors
PR-progesterone receptors
HER2-human epidermal growth factor receptor 2
163
ER positive breast cancer is
expressed in 60-70% of breast cancers
dependent on oestrogen to control tumour growth
better prognosis
164
HER2 breast cancer assoc,
25-30% breast cancers
assoc. to aggressive behaviour and high risk lymph node involvement
- cell surface receptor involved in cell growth and differentiation
165
Ki-67 assoc. to breast cancer
marker of cell proliferation
| assoc. to better response to neo-adjuvant chemo but overall prognosis is poorer
166
triple negative breast cancer meaning and who
-dont have ER, PR or HER2
-15%
more seen in pre-menopausal, BRCA1 gene
-most express EGFR epidermal growth factor receptor
167
diagnosis breast cancer
```
triple assessment
mammo or USS
MRI
FNAC or core
vacuum assisted biopsy
USS of axilla
blood test
```
168
early breast cancer staging inx
-blood test- LFT and calcium
x-ray chest
USS liver
sentinel lymph node biopsy
169
locally advanced breast cancer staging
```
-CT scan
MRI
bone scan
liver USS
blood tests
sentinel lymph node biopsy
```
170
what is a sentinel lymph node biopsy
need to dx whether there is a cancer in the lowest level of lymph nodes- ie closest to the cancer
alterantive is 4 node sampling but SNLB is first line
171
management if sentinel lymph node biopsy is positive
need definitive axillary surgery and clearance
172
risks of axillary clearance
lymphoedema
173
mets of breast cancer
liver lung bone brain
| axilla
174
non invasive insitu managemetn options
- simple mastectomy
- wide excision alone or breast conserving surgery
- wide excision and post-op radiotherapy
175
when would a mastectomy be indicated over a wide local excision
mastectomy if
- central tumour
- multifocal tumour
- large lesion in small breast
- DCIS >4cm
176
LCIS management
close monitoring
177
low grade DCIS management
wide local excision
178
high grade DCIS management
| DCIS in two or more quadrants
mastectomy (multifocal) and post-op radiotherapy
179
DCIS in males management
mastectomy
180
recurrence DCIS
mastectomy
181
early breast cancer management
breast conserving surgery- lumpectomy
and SNLB
+/- axillary clearance
182
locally advanced breast cancer management
neo-adjuvant chemotherapy
mastectomy or lumpectomy
axillary clearance
183
advanced breast cancer management
salvage mastectomy with or without reconstruction
| axillary clearance
184
patients suitable for breast conservation
-primary tumour/ breast size will give satisfactory cosmesis aka
small tumour, large breast, localised, no nipple, peripheral
-able and willing to tend for follow up
-suitable for radiotherapy
-patient choice
185
patients not suitable for breast conservation surgery
```
unable to have post-op radiotherapy
severe lung and heart disease
pes excavatum
chronic lack of mobility of shoulder
kyphoscolisosis
large tumour small breast
DCIS >4cm
multifocal
central tumour around involving nipple
```
186
breast conserving surgery margins and exceptions
needs to be 1 mm
unless
-posterior tumour margin abutting on pectoral fascia acceptable <1mm
-anterior tumour margin abutting on subcutaneous fascia acceptable <1mm
187
mastectomy indications
- patient choice
- cosmemsis after breast conservation likely to be poor
- multifocal
- bilateral disease
- >4cm DCIS
- technically unsuitable for breast radiotherapy
- significant fhx
- central tumour
188
mastectomy and reconstruction
generally offered
| -primary reconstruction may be avoided if chest wall radiotherapy likely to be indicated
189
if not using SLNB how many nodes must be sampled
at least 4
190
types of breast reconstruction
-either as immediate or delayed
1. implant/ expander
2. latissimus dorsi muscle flap
3. free tissue transfer eg from stomach TRAM/DIEP flap
191
radiotherapy of whole breast indications
1. all patients after breast conserving surgery
2. no lymph node mets in an adequate axillary node sample of 4 nodes
3. >4 nodes positive
4. women <50 at surgery
5. invasive disease with inadequate excision margins unsuitable for re-excision
6. conserved breast unsuitable for excision
7. T4 disease at presentation
192
radiotherapy for chest wall indications
-after mastectomy in some cases
| tumour size >5cm, 4 or more involved nodes and involved resection margins
193
radiotherapy for axilla indications
- involved axillary node sampling if patient does not want axillary clearance
- not indicated after axillary node clearance unless residual disease left
194
chemotherapy for breast cancer indications
early breast cancer
- reduce risk of relapse
- grade 3, LVI, nodal involvement, triple negative, HER2+
locally advanced disease
metastatic disease
195
what chemo is given for breast cancer
cyclophos
methotrexate
5 fu
196
how is chemo given for breast cancer
-can be neo-adjuvant eg to shrink down for surgery
to do breast conserving
- or adjuvant
197
medical treatments given in breast cancer
-hormone, tamoxifen, aromastase
-chemotherapy
-biological
-bisphosphonates
radiotherapy
198
determining if patient is post-menopausal and >50yrs
Check hormones 6/52 off tamoxifen
FSH>30 on 2 occasions 6/52 apart confirms menopause if amenorrhoeic for 24 months. If patient on Zoladex hormones return to baseline levels after 2/4 weeks
199
determine post-menopausal 50-54
check hormones after 6 weeks off tamoxifen.
| FSH>30 on 2 occasions 6/52 apart confirms menopause if ammenorroiec for 12 months
200
determine post-menopausal >54 and amenorrhoeic for 12 months
no need to check
| if patient has PV bleed then stop
201
prognostic factors of breast cancer
```
lymph node status
tumour size
grade I-III
lymphatic/ vascular
biological factors
```
202
breast cancer follow up yr1
clinical and mammogram
| check hx
203
breast cancer follow up yr 2-4
mammogram only
204
breast cancer follow up yr 5
-clinical exam
mammogram
if on endocrine therapy consider switching, extending or stoping
205
breast cancer follow up yr 6-10
mammogram only with clinic appointment yr 10 if on endocrine treatment
206
HER2+ additioanl management
- chemotherapy-docetexal, paclitaxel
| - Herceptin -transtuzumab
207
ER+ additional management pre menopause and men
-tamoxifen
goserelin
oophorectomy
208
ER + additional management post menopausal
aromatase inhibitors
| fulvestrant
209
reducing risk of recurrence of breast cancer ER+
-USE TAMOXIFEN OR LETROZOLE
- tamoxifen if low risk postmenopausal or aromatase CI
- aromatase can be switched too if after 5 yrs on tamoxifen for higher grades (post menopausal)
210
indications for bisphosphonates for breast cancer
node positive invasive breast cancer
| reduces risk of bony mets in later life
211
tamoxifen indication
- ER positive breast cancer
- anovulatory infertility
- primary prevention of breast cancer for women at high risk BRCA
- adjuvant treatment
- Ductal carcinoma in situ
212
action of tamoxifen
SERM selective estrogen receptor modulator
oestrogen receptor antagonist
anti-oestrogen which induces gonadotrophin release by occupying oestrogen receptors in the hypothalamus- so interferes with feedback mechanisms
binds to oestrogen receptors
213
administration of tamoxifen
oral
214
SE of tamoxifen
```
alopecia
anaemia
cataracts
cerebral ischaemia
constipation
diarrhoea
dizziness
embolism and thrombosis
fluid retention
headache
menstrual disturbance- vaginal bleeding, amenorrhoea
hot flushes
endometrial cancer
osteoporosis
vulvovaginal disorders
- rare- agranulocytosis
```
215
contrainidcations to tamoxifen
pregnancy
hypersensitivity
concurrent anastrozole therapy
personal hx or fhx of VTE
216
drug interactions of tamoxifen
anastrazole
hormonal therapy
warfarin- enhances
cyp450
217
aromatase inhibitors example
anastrozole,-type 1 oral steroidal
letrozole- type 2
exemestane
218
indication for aromatase inhibitors
- post menopausal ER positive breast cancer
- can also be adjuvant treatment following 2-3 yrs of tamoxifen therapy
- neo-adjuvant to try and shrink
219
action of aromatase inhibitors
in post-menopausal women peripherlal oestrogen synthesis from aromatase in adipose tissue
-aromatisation blocking reduce oestrogen
220
administration of aromatase
oral
221
monitoring on aromatase
need DEXA scan due to risk of osteoporosis
222
SE of aromatase
```
alopecia
hot flushes
tired
muscle pain
dry skin
hair thinning
sweats
reduced appetite
arthritis
insomnia
osteoporosis
```
223
contraindications to aromatase
```
pregnancy
pre-menopausal
breast feeding
use with caution in liver failure
avoid if CrCL <20
hypersensitivity to lactose
```
224
drug interactions aromatase
dont give with tamoxifen or oestrogen containing therapies
225
goserelin zoladex indications
prostate cancer
oestrogen receptor positive breast cancer
endometriosis
fibroids
226
action of Goserelin
```
GnRH analogue
initial stimulation of GnRh
then donw regulation of gonadotrophin releasing hormone receptors
reduce FSH and LH
reduce oestrogen
```
227
administration of goserelin
SC
| implant
228
contraindications of goserelin
undx vaginal bleeding
pregnancy
breast feeding
229
side effects goserelin
```
prolong QT
greater risk cord compression
alopecia
arthralgia
bone pain
breast abnormalities
depresssion
glucose tolerance
gynaecomastia
hypercalcaemia
```
230
Herceptin is
transtuzumab
231
herceptin indication
breast cancer with HER2 positive
| gastric cancer HER2
232
HER2 pathology
normally HER2 controls healthy breast cell growth
but in cancer HER2 human epidermal growth factor receptor becomes an oncogene and are overexpressed (make too many copies)
promotes uncontrolled cell growth and proliferation when overexpressed
233
herceptin mechanism of action
monoclonal antibody targets HER2 to prevent it being overexpressed
234
administraction herceptin
IV
| SC
235
Contraindications to herceptin
severe dyspnoea at rest
caution in heart problems
avoid in pregnancy and breast feeding
236
SE herceptin
```
alopecia
anaemia
angioedema and dyspnoea
arthritis, asthma
GI problems
infusion reactions
```
237
monitoring needed for Herceptin
cardiotoxicity
238
drug interactions of herceptin
vaccines
| drugs cardiotoxic
239
Imatinib action
tyrosine kinase inhibitor
240
imatinib indications
haem malignancies
-CML
ALL
GIST tumours
dermatofibrosarcoma protuberans
241
interactions SE of imatinib
```
infection risk
alopecia
anaemia
chills and constipation
cough
nandv
photosensitivity
thrombocytopaenia
```
242
administration imatinib
oral
243
CI imatinib
pregnnacy
| breast feeding
244
monitoring imatinib
GI
bloods
growth in children
245
capecitabine indications
colon cancer
gastric cancer
breast cancer
246
action of capecitabine
metabolised to fluorouracil in the liver which is a thymidylate synthase inhibitor
chemo medicaiton
247
CI to capecitabine
```
dihydropyrimidine dehydrogenase deficiency
avoid in pregnancy
discontinue breast feeding
avoid if CrCL <30
severe neutropaenia
lactose intolerant
avoid live vaccines
```
248
capecitabine SE
```
alopecia, anaemia, chest pain, na and v
hypokalaemia
hand and foot syndrome
mouth sores and ulcers
risk of neutropaenia
depression, thrombosis,
thrombocytopaenia, cardiac
```
249
monitoring for capecitabine
calcium
eyes
skin
hand and foot
250
drug interactions capecitabine
warfarin
sorivudine
phenytoin
calcium folinate
251
rituximab indications
non hodgkin lymphoma
CLL
pemphigus vulgaris
252
action rituximab
monoclonal antibody to B cells
253
administration rituximab
IV
| SC
254
CI rituximab
cardiac
pregnnacy
breast feeding
live vaccines
255
SE rituximab
```
alopecia
anaemia
conjunctivitis
GI
depression
increased risk of infection
MI
neutropaenia
pain
thrombocytopaenia
tumour lysis syndrome
infusion related se
```
256
ZOLEDRONIC acid indication
hypercalcaemia of malginancy
bone mets
node positive breast cancer
steroid induced osteoporosis
257
action of zoledronic acid
binds to hydroxyapatite crystals in bone
disrupts osteoclasts
prevent break down
258
interactions of zoledronic acid
calcium
diuretics
gentamycin
259
toxicity signs zoledronic acid
amount of urine, muscle spasms weakness, mood, heart beat seizures
260
monitoring zoledronic acid
-blood test
| must be on birth control
261
inx of prostate cancer
```
PSA
DRE
MRI prostate
TRUS transrectal biopsy
gleason score
```
262
localised prostate cancer treatment options
observation-watchful waiting
active surveillance
radiotherapy and bracytherapy
surgical
263
complications prostate cancer management
- surgery- impotence/ incontinence
| - radiation- proctitis, cystitis
264
metastatic prostate cancer management
Goserelin
bicalutmide and casodex- anti androgen -give with first injection of goserelin to prevent rise
LHRH antagonist- firmagon/ degarelix
orchidectomy
plus chemo
palliative radiotherapy if bone mets
265
colorectal cancer inx
```
bloods
sigmoidoscopy
biopsy
barium enema
colonoscopy
USS
MRI
CT
```
266
FAP
familial adenomatous polyposis
autosomal dominant
lots of polyps
APC andeomatous polyposis colii gene
267
HNPCC hereditary non polyposis colorectal carcinoma
autosomal dominant
| mutation MLH1 MSH2 DNA mismatch repair gene so get microsatellite instability
268
neo-adjuvant management of rectal cancer
-radiotherapy
| chemotherapy
269
management of GI cancers
-rectal only get neo-adjuvant
surgical
-adjuvant chemotherapy - capecitabine or oxaliplatin
270
side effects of radiotherapy
-normal tissue complications
-acute toxicities- lethargy, erythema, mucosal, alopecia
-late toxicities- GI, neuro, MSK,resp, lymphoedema
-infertility
second malignancies
cardiac toxic
271
management of acute skin toxicities radiotherapy
aqueous cream
| prophylactic use of bethamethasone- topical steroid
272
minimising toxicities of radiotherapy
positioning
cardiac shielding eg MLC
breathing manoeuvres
273
what is bracytherapy
sealed radiation source is placed inside or next to the area requiring treatment
274
LUNG CANCER presentation
```
asymptomatic
invasive symptoms eg SVCO
dysphagia
horner
airway symptoms
systemic
finger clubbing
HPOA
```
275
where does lung cancer spread
```
lumph nodes
adrenals
pleura
liver
skin
bones
brain
```
276
types of lung cancer
SCLC 15%
NSCLC
-adenocarcinoma
squamous
large cell
277
adenocarcinoma lung
- more common type in non-smokers
| - overall most common
278
large cell lung cancer
peripheral
anaplastic, poorly differentiated
poor prognosis
279
squamous cell lung cancer
```
-slower growing
paraneoplastic
-hypercalcaemia- ectopic PTH
-finger clubbing
-hyperthyrodisim produces TSH
HPOA
central
```
280
small cell lung cancer feature
grows faster
smoking related
arises from APUD cells
-ectopic ADH and ACTH
SIADH- hyponatraemia
ectopic ACTH- cushing like, adrenal
Eaton lambert- myasthenia gravis like
281
mesothelioma lung
linked to asbestos
282
INX for lung cancer
1. CXR
2. CT CA with contrast
3. tissue collection
- bronchoscopy for central lesions
- EBUS
- CT guided percutaneous tranthroacic FNA for peripheral lesions
4. CT PET if surgical considered stages 1-3
283
small cell lung cancer management
usually metastatic by dx
can resect if early
chemo cisplatin and radiotherapy
SACT
284
non small cell management
- surgery and chemoradiotherapy
| - tyrosine kinase inhibitor for eGFR mutation
285
causes of pulmonary mets
```
renal
breast
colorectal
bladder
remember big colourful balls
```
286
types of ovarian cancer
-epithelial tumours
serous 50% malignancy
mucinous 10%
endometrioid 25%
Germ cell tumours
teratoma- mostly benign, increased AFP, teeth hair and bone
germinoma- most common younger women
sex cord tumour
-granulosa
thecomas
287
main biomarker for ovarian cancer
ca125
288
management ovarian cancer
surgical- full hysterectomy with bilatearl salpingo-oophorectomy and partial omentectomy
in young women wishing to preserve fertility and early stage may be able to just remove the ovary affected
chemotherapy
289
neutropaenic sepsis pathology
patients on SACT
-cytotoxic drugs target high rapid dividing cells so stem cells also get affected and get neutropaenia
-also affects mucosa and break down of gastric mucosa means bacteria can get across
290
definition of neutropaenic sepsis
patient on chemotherapy
neutrophil count <0.5 and either
-temp >38
signs of symptoms of sepsis
(in practice dont wait for neutrophil count)
291
presentation of neutropaenic sepsis
temperature >37.5 or <36.5
-not always
symptoms
-sspsi
unwell
patient at risk especially 7-21 days post SACT
292
assessment of Neutropaenic sepsi
admission-preferrably onto oncology
NEWS
MASCC score
-specific risks to look for
catheters, wounds, previous MRSA colonisation, atypical resp pathogens
IV access- take bloods and cultures
antibiotics empirical
293
DEFINING high and low risk in neutropaenic sepsis
MASCC score
- greater than or equal to 21 are standard risk
- less than 21 are high risk
NEWS score greater than or equal to 6 is automatically high risk independent of the MASCC score
high risk also if
-BP <90
shocked
PS 3 and above
or 2 of
- dehydration
- COPD
- PS 2 or more
- previous fungal
- inpatient when developed
- age >60
294
inx for neutropaenic sepsis
SEPSIS 6 and initial assessment
```
hx and exam
bloods
cultures from blood and lines
viral throat swabs
urine
imaging- CXR, CT
stool cultures
```
295
antibiotics for standard risk
21 or above MASCC, or 5 or less NEWS
- IV piperacillin and tazobactam- tazocin
- 1st dose give regardless of renal function
- after that tailor dose to creatinine
also cover any specific risks
- vancomycin for MRSA
- clarithromycin for atypical pneumonia
allergies-true penicillin
-vancomycin, metronidazole, IV azetreonam
if mild allergy
-ceftazidime+ IV gentamicin+ metronidazole
296
MASCC <21 or News 6 and above
IV piperacillin/ tazobactam and IV gentamicin
- if clear hx of renal impairment need to refer to guidelines and discuss with microbio
- again dose both with creatinine levels
297
other management option for neutropaenic sepsis
```
Granulocyte- colony stimulating factor
-profound neutropaenia <0.1
prolonged >10days
pneumonia
hypotension
multiforgan dysfunction
invasive fungal
>65
hospital inpatient at the time
```
298
presentation of malignant cord compression
```
pain -back pain- radicular pain- band like
weakness bilateral or unilateral
sensory or autonomic disturbance
bowel problems- constipated
altered sensation
urinary problems
faecal incontinence
paraplegia
UMN signs if >l1
LMN signs if
```
299
main causes of malginant cord compression
-breast
lung
prostate
myeloma
300
types of cord compression
complete compression
anterior compression- pain and temp
-posterior- vibration and position
lateral- brown sequard pain and temp
301
dx of cord compression
URGENT MRI OF WHOLE SPINE
302
cauda equina is
compression below L1/2
sciatic pain, bladder dysfunction and retention, overflow incontinence, impotence, saddle anaesthesia, loss of anal sphincter tone, weakness and wasting of gluteal muscles
303
treatment of malignant cord compress acute
```
-lie flat
steroids- immediate dexamethasone plus PPI cover
analgesia
thromboprophylaxis
prompt physio
ensure spine stable
```
304
next mangement of malignant cord compress
- radiotherapy- mainstay of treatment
start as soon as practical, llie supine
-surgical- laminectomy
- chemotherapy-usually after RADIOTHERAPY-mainstay
- hormone therapy -prostate
305
radicular pain plus active or recent cancer is
malignant cord compression until determined otherwise
306
SVCO is
obstruction of blood flow through the SVC
| due to compression, invasion or intra-luminal thrombus in SVC
307
causes of an SVCO
-lung cancer 80% bronchus more non small cell
lymphoma
other malignancies
benign causes: aneurysm, goitre, fibrosis, infection, central line in situ
other
-blood clots
TB
aortic aneurysm
308
symptoms of SVCO
```
often insidious over time
swelling of face, neck, arms
distended veins
SOB
headache
lethargy
conjunctival suffusion- red eye
nasal congestion
epistaxis
dizziness
syncope
worse on bending forwards
```
309
assessment SVCO
- extent
| - any evidence of malginancy elsewhere eg lymphs, collapsed lung
310
signs of SVCO
```
non pulsatile raised JVP
collateral venous
arm oedema
plethora
acute unwell patient in cases sudden occlusion
```
early stage= puffy neck and veins
later= distended veins, swollen face, neck and arms
311
cause of obstruction SVCO
within
- clot
- foreign body
- tumour eg renal cancer
extrinisc compression
312
inx SVCO
```
usually not an emergency so inx
-CXR-widened mediastinum
-venogram
CT chest
bloods
mass-biopsy
```
313
treatment SVCO in emergency
```
A to E
sit upright
oxygen
dexamethasone and PPI
if clot- anticoagulant, line removal if present
```
extrinisc compression
- dexamethasone
- radiological stent insertion
- chemo-SCLC, lymphoma and teratoma
- radiotherapy -solid tumours
314
treatment SVCO in emergency
```
A to E
sit upright
oxygen
dexamethasone and PPI
if clot- anticoagulant, line removal if present
```
extrinisc compression
- dexamethasone
- radiological stent insertion
- chemo-SCLC, lymphoma and teratoma
- radiotherapy -solid tumours
315
definition of malignant hypercalcaemia
hypercalcaemia >2.65 on two occasions following adjustment for serum albumin concentration
-urgent intervention needed if >3
316
mechanisms of malignant hypercalcaemia
- osteolytic measures due to bone mets-release protein that increase osteoclast activation
- circualting PTHrP or calcitriol released
317
tumours that release PTHrP
```
squamous carcinomas of lungs
head and neck
renal
bladder
ovarian
```
318
tumours that release calcitriol
lymphoma-hodgkin's
319
inx for tumour PTHrP findings
low vit D-calcitriol
high PTHrP
low PTH
320
inx for osteolytic measure tumour findings
low PTH
low calcitriol or normal
low PTHrP
321
calcitonin function
meant to reduce calcium re-uptake and increase calcium bone deposition when calcium is high
322
severity hypercalcaemia
mild=2.65-3
mod 3.01-3.40
severe >3.40
323
malignant causes of hypercalcaemia
```
lung
breast
myeloma
osteolysis lytic bone mets
humoral mediators
dehydration
tumour specific mechanisms eg myeloma depositis bence proteins in kidneys which decreases calcium excretion
```
324
clinical features of hypercalcaemia
-stones bones groans moans overtones, thrones
bone pain
neuromuscular- droswy, delirium coma, fatigue depression, n and v, weight loss, constipation
renal: polyuria, polydipsia, dehydration
cardio: HTN, shorten QT
325
INX hypercalcaemia
-calcium
-renal function
PTH - high suggest primary hyperparathyroidism- throid gland
vit D high or low depending on cause
ECG- increased PR interval, widened QRS
326
management <3 calcium
no active treatment needed
| avoid dehydration and medications
327
management 3-3.5
-generally no active treatment unless symptomatic or acute
symptomatic- fluid replacement 0.9% sodium chloride
328
management calcium >3.5
emergency treatment needed
rehydration-IV fluids first
bisphosphonates-zoledronate- IV
give Pamidronate if GFR <30
review medication
check renal function in 3-4 days- (rescue zoledronate)
haemofiltration- dialysis if not responding
329
SE of bisphosphonates
```
GI upset
flu like symptoms
exacerbation of metastatic bone pain
ostenecrosis of the jaw
hypocalcaemia
```
330
other drug options for hypercalcaemia
- salcatonin- calcitonin
- gallium nitrate- inhibits osteoclatic bone resporption and inhibits PTH
- dialysis if severe who have good prognosis and adequate hydration cannot be achieved due to renal or cardiac failure
331
malignant pericardial effusion causes
-thoracic malignancies such as lung cancer, mesothelioma or metastatic disease
332
presentation of malignant pericardial effusions
acute dyspnoea
chest pain
rapid accumulation of fluid or pericardial stiffening due to the tumour can result in tamponade with worsening symptoms including orthopnoea, cough, syncope
-heart sounds muffled and pericardial rub
-apex beat not detectable
-low bp
pulsus paraodxus
333
inx for malignant pericardial effusion
ECG
CXR
ECHO confirm
aspiration
334
CXR signs of pericardial effusion
- increased cardiothoracic ratio
| enlarged globular heart
335
management of pericardial effusion
-drain by needle under radiological control
-surgical procedure of pericardial window formation
treat underlying cancer
336
tumour lysis syndrome cause
-syndrome of metabolic abnormalities and renal impairment due to massive lysis of a rapidly proliferating tumour cells resulting in the release of intracellular contents into the circualtion
337
patient with large volume malignant disease develops acute renal failure
tumour lysis sundrome
338
which tumours are assoc. to tumour lysis
-poorly differentiated lymphomas
leukaemias
germ cell tumours
breast myeloma
-chemo sensitive tumours
339
presentation tumour lysis syndrome
recent chemotherapy/ initiation- can also be spontaneous in tumours with high turnover or following steroid monotherapy for lymphoma
```
bulky chemo sensitive cancer
oliguric
HTN
tachycardic
fatigue
weakness
N and V
```
340
metabolic abnormalities of tumour lysis syndrome and presentation
1. hyperuricaemia
- release of nucleic acids metabolised to uric acid
- then depositis in renal tubules and causes acute uric acid nephropathy
- oliguric ARF
2. hyperphosphateamia
- 2ndary to release of intra-cellular phosphate
- malignant cells have higher phosphate
- precipitate with calcium deposits in kidney- ARF
3. hyperkalaemia
- exacerbated by deteriorating renal function
- cardiac- ECG tall t, loss p, wide qrs, sine wave
4. hypocalcaemia / hypomagnesia
- secondary to increase phosphate
- muscle weakness and tetany
5. Acute renal failure
- uric acid and phosphate deposit
6. metabolic acidosis
341
patients at risk of tumour lysis syndrome
1.-patients specific- baseline metabolic abnormality
2. suboptimal renal function
3. large volume, rapid cell turnover, chemo sensitive tumours
4, especially lymphomas, leukaemias, germ cell tumours
342
preventing tumour lysis syndrome
1. optimise renal function before and during treatment
- relieve any obstruction
- correct any existing electrolyte abnormalities
- ensure adequate fluid replacement
- (mannitol)
2. if low risk- absence of pre-treatment hyperiuricaemia
- allopurinol can be given pre-chemo for 48 hrs to decrease incidence of post-treatment hyperuric
3. if high risk- presence of pre treatment hyperuricaemia
-rasburicase given (recombinant urate oxidase)
-degradation of uric acid
1-7 DAYS
CI G6PD
-leucophoresis if blast count high
343
management of tumour lysis syndrome
```
-urgent correct hyperkalaemia
fluid balance monitor
urinalysis- uric acid crystals
exclude post-renal cause USS
monitor renal function
calcium supplementation
consider alkalinising the urine-sodium bicarb
haemodialysis
```
344
main cancer pains
```
bone
nerve compression
visceral pain
muscle spasm
soft tissue pain
post-op pain
neuropathy
back pain
capsulitis shoulder
constipation
```
345
neuropathic pain cause
nerve damage
burning, sharp, pins and needles
allodynia may occur
can be localised to dermatomes
346
WHO analgesic ladder
1. non opioid
-paracetamol
NSAID
2. mild opioid eg codeine
3. strong opioid for moderate to severe pain
eg morphine
347
SE opioids
```
DESIGNER
dry mouth
euthoria
sedation
itch
GI
nausea
eyes
resp depression
```
348
opioid toxicity
```
confusion
drowsiness
myooclonic jerk
hallucinations
peripheral shadows
```
349
withdrawal symptoms of opioids
n and v
diarrhoea
depression
350
strong opioids
```
morphine
diamorphine
fentanyl
oxycodone
alfentanil
methadone
```
351
weak opioids
```
codeine
co-codamol
dihydrocodeine
tramadol
buprenorphine
```
352
codeine
metabolised to morphine at liver
| avoid in CKD 4 and 5
353
dihydrocodeine
similar to codeine
metabolised in liver
avoid in CKD 4 and 5
354
tramadol
```
also an opioid
but different chemically
renal excreted
use with caution in CKD 4 and 5
CI if on MAOI or epilepsy
```
355
buprenorphine patches
7 day patch
treats moderate pain
CI in patients with acute short term pain and in those who need rapid dose titration for severe uncontrolled pain
can be used in CKD 4 and 5
356
morphine
immediate or modified release
oral or parenteral
cautions
- frail or elderly
- liver impairment
CI
-CKD 4 and 5
prescribe with stimulant/ laxative and anti-emetic
357
diamorphine
```
parenteral
SC and pump
highly soluble
use for high dose SC breakthrough
avoid in CKD 4 and 5
```
358
oxycodone
moderate to severe pain if morphine/ diamorphine not tolerate
immediate, modified, oral and parenteral
moderate forms CI in
- CKD 4 and 5
- moderate to severe liver impairment
359
fentanyl patches
transdermal patch lasts 72 hours
use if oral and SC routes are unsuitable
can be used in CKD
indication
-for stable pain if morphine not tolerated
second line opioid
oral and SC not suitable
patient unable to tolerate morphine/ diamorphine
360
opioid toxicity
precipitated by dose escalation, renal impairment, sepsis, electrolyte abnormalities, drug interactions
361
presentation opioid toxicity
```
persistent sedation
vivid dreams, hallucinations, myoclonus jerking
confusion
delirium
muscle twitch
```
362
management opioid toxicity
if pain controlled reduce opioid by 1/3
ensure hydrated
for agitation can give haloperidol
if patient is still in pain consider reducing dose by a 1/3 and consider adjuvant analgesics
naloxone only for life threatening severe resp depression
363
causes of pain
total pain-interaction in nervous system of all physical and emotional aspects
disease related- direct invasion of organ, pressure, cancer, distension
bone pain- worse on pressure, stress
nerve pain- burning shooting, tingling
liver pain- RUQ pain, referred shoulder tip
raised ICP- headache worse on lying
colic: intermittent cramp
cancer pain related- eg liver capsule, plexopathy, coelaic plexus
364
pain management
mild pain
1. paracetamol/ NSAID
2. weak opioid- codeine, dyhydrocodeine, buprenorphine, tramadol
moderate to severe pain
1. morphine and stop any weak opiods
2. nerve blocks, epidurals,
365
anorexia in cancer causes
```
-neurohumoral
multifactoial
metabolic
reduced fuel supply
accelerated metabolism
```
366
causes cancer related fatigue
```
depression
anaemia
cancer rx
tumour bulk
cytokine release
```
367
delirium definition
disturbed consciousness and inattention with cognitive impairment
delirium is often reversible
fluctuating state of lucid points with confusion, hallucination, agitation
368
three types delirium
hyperactive
hypoactive
mixed
369
causes of delirium
```
drugs- opioids, ach, steroids, benzos, anti dp
drug withdrawal- alcohol, sedatives, adp
dehydration, constipation, urianry retention
uncontrolled pain
liver renal imapirment
electrolytes
infection
hypoxia
metabolic
cancer treatment eg cranial radiotherapy
brain mets
paraneoplastic syndromes
substance abuse
visual impairment and deafness are RF
```
370
inx delirium
bloods
infection
review all meds and stop any non essential drugs
assess sensory impairment
check for opioid toxicity
check for constipation, retention, catheter
