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Surgery.(General 2).Breast > 4. Carcinoma of the female breast. (Treatment and follow up) > Flashcards

4. Carcinoma of the female breast. (Treatment and follow up) Flashcards

1
Q

Modalities of treatment of breast cancer

A

I- Surgical

II- Radiotherapy

III- Chemotherapy

IV- Hormonal treatment

V- Immunotherapy

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2
Q

Surgical modalities of treatment of breast cancer

A

1- Radical mastectomy: not done now

2- Extended radical mastectomy : not done now

3- Modified Radical mastectomy (MRM)

  1. Simple mastectomy
  2. Conservative breast surgery
  3. Reconstructive breast surgery :
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3
Q

Radical mastectomy in surgical modalities of treatment of breast cancer

A
  • Alternative name
  • Indication
  • Procedures
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4
Q

Alternative name for Radical mastectomy in surgical modalities of treatment of breast cancer

A

Halsted

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5
Q

Indication of Radical mastectomy in surgical modalities of treatment of breast cancer

A

not done now

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6
Q

Procedures of Radical mastectomy in surgical modalities of treatment of breast cancer

A

we remove:

1- The whole breast tissue.

2- Pectoralis major & minor muscles ( and interpectoral L.N)

3- All fat, fascia & L.Ns of the axilla

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7
Q

Extended radical mastectomy in surgical modalities of treatment of breast cancer

A
  • Alternative name
  • Indication
  • Procedures
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8
Q

Alternative name for Extended radical mastectomy in surgical modalities of treatment of breast cancer

A

Urban

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9
Q

Indication of Extended radical mastectomy in surgical modalities of treatment of breast cancer

A

not done now

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10
Q

Procedures of Extended radical mastectomy in surgical modalities of treatment of breast cancer

A

we remove:

1- The whole breast tissue.

2- Pectoralis major & minor muscles ( and interpectoral L.N)

3- All fat, fascia & L.Ns of the axilla

4- The internal mammary L.N. through removal of the homolateral 1/2 of the sternum & the costal cartilages from 2-5.

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11
Q

Procedures of Modified Radical mastectomy (MRM) in surgical modalities of treatment of breast cancer

A

We remove : Whole breast & axilla.

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12
Q

Simple mastectomy in surgical modalities of treatment of breast cancer

A
  • Procedures

* Indications

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13
Q

Procedures of simple mastectomy in surgical modalities of treatment of breast cancer

A

we remove Breast only.

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14
Q

Indications of simple mastectomy in surgical modalities of treatment of breast cancer

A

Palliative in stages III & IV caner breast.

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15
Q

Conservative breast surgery in surgical modalities of treatment of breast cancer

A
  • Procedures
  • Indications
  • Contraindications
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16
Q

Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

either:

1- QUART:

2- TART:

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17
Q

QUART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

A
  • QU: Quadrantectomy
  • A: Axillary clearance or sampling
  • RT: Radiotherapy to the breast
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18
Q

TART in Procedures of Conservative breast surgery in surgical modalities of treatment of breast cancer

A
  • Lumpectomy with safety margin 2 cm +
  • Axillary clearance
  • Radiotherapy to the breast
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19
Q

Indications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

Now all females do conservative breast surgery
but in the past, the indications were:

a) Done only in stages I and ll
b) Young age.
c) Small tumour up to 4 cm or up to 5 cm in large breast.
d) Tumour away from nipple & areola.

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20
Q

Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A
  • Absolute

* Relative

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21
Q

Absolute Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

a) Extensive intraductal (in situ) component.
b) Lobular carcinoma.
c) Grade III tumours.
d) 1st & 2nd trimester of pregnancy.
e) Recurrence after radiotherapy or history of prior radiation to area of treatment.
f) Collagen disease.

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22
Q

The reason why Extensive intraductal (in situ) component is considered from the absolute contraindications of Conservative breast surgery

A

as it behaves like multicenteric Known by biopsy

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23
Q

The reason why Lobular carcinoma is considered from the absolute contraindications of Conservative breast surgery

A

as it mulicentric

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24
Q

the reason why Grade III tumours are considered from the absolute contraindications of Conservative breast surgery

A

as they are undifferentiated

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25
Q

the reason why 1st & 2nd trimester of pregnancy. are considered from the absolute contraindications of Conservative breast surgery

A

Harmful effects of radiotherapy on the fetus

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26
Q

the reason why history of prior radiation to area of treatment is considered from the absolute contraindications of Conservative breast surgery

A
  • rule : no radiotherapy on top of previous radiotherapy

* Due to presence of much fibrosis by previous radiotherapy

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27
Q

the reason why Collagen disease is considered from the absolute contraindications of Conservative breast surgery

A

thin weak Skin of patients with collagen disease can’t tolerate radiotherapy

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28
Q

Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

a) Large tumour > 5 cm or > 4 cm
b) Small breast (bad cosmetic result).
c) Tumour affecting nipple or areola.

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29
Q

The reason why Large tumour > 5 cm or > 4 cm is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

as down staging can be done by 3 courses of chemotherapy

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30
Q

The reason why Small breast is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

as Breast reconstruction and augmentation mammoplasty can be done

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31
Q

The reason why Tumour affecting nipple or areola is considered from the Relative Contraindications of Conservative breast surgery in surgical modalities of treatment of breast cancer

A

as Nipple & areola reconstruction can be done

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32
Q

Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A
  • Components
  • Indications
  • Bailey and love note
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33
Q

Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A

A. Breast reconstruction :

B. Nipple & areola reconstruction :

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34
Q

Modalities of Breast reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A
  1. Silicone gel implants under the pectoralis major
  2. Expandable saline prosthesis.
  3. Myocutaneous flaps
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35
Q

Procedures of Myocutaneous flaps in Modalities of Breast reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A

a) Transverse rectus abdominis muscle flap (TRAM flap)

b) Latissimus dorsi muscle flap (LD flap).

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36
Q

Modalities of Nipple & areola reconstruction in Components of Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A
  1. Prosthetic nipple or partial contralateral nipple graft

2. Tattooing is the simplest technique for areola reconstruction.

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37
Q

Indications of Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A

Done only after MRM in stages I & II

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38
Q

Bailey and love note on Reconstructive breast surgery in surgical modalities of treatment of breast cancer

A

To achieve symmetry the opposite breast may require reduction or augmentation mammoplasty

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39
Q

Chemotherapy in modalities of treatment of breast cancer

A
  • Indications
  • Drug combinations
  • Regimens
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40
Q

Indications of Chemotherapy in modalities of treatment of breast cancer

A

It will be of great benefits for hormonal receptors negative

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41
Q

Drug combinations in Chemotherapy in modalities of treatment of breast cancer

A
  1. CMF : Combination of Cyclophosphamide, Methotrexate & 5- Fluorouracil.
  2. Adriamycin alone.
  3. CAF : Combination of Cyclophosphamide, Adriamycin & 5- Fluorouracil
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42
Q

Regimens of Chemotherapy in modalities of treatment of breast cancer

A
  • CMF or Adriamycin alone is given in a 6 monthly cycles.
  • CAF:
    ln 4 monthly cycles when given instead of CMF.
    ln 6 monthly cycles in aggressive tumours
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43
Q

what is the meaning of 6 monthly cycles

A

Few days in each month Not the whole month

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44
Q

Hormonal treatment in modalities of treatment of breast cancer

A
  • Hormonal receptors
  • Management of hormone receptors positive in postmenopausal women
  • Management of hormone receptors positive in premenopausal women
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45
Q

Hormonal receptors in Hormonal treatment in modalities of treatment of breast cancer

A
  • Estrogen receptors ( ER )
  • Progesterone receptors ( PR ).
  • Presence of PR indicates there are much estrogen receptors
  • No PR positive tumours exist
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46
Q

Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  1. Tamoxifen

2. Anastrazole & Letrozole ( Femara ).

47
Q

Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  • Mechanism of action
  • Significance
  • Dose
48
Q

Mechanism of action of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

SERM

Selective Estrogen Receptor Modulator

49
Q

Significance of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

It’s the drug of choice

50
Q

The drug of choice in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

Tamoxifen

51
Q

Dose of Tamoxifen in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

20 mg / day for 5 years

52
Q

Anastrazole and Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  • Mechanism of action

* Trade name of Letrozole

53
Q

Mechanism of action of Anastrazole and Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

They inhibit aromatase enzyme responsible for conversion of androstenedione produced by the adrenal glands to estrone ( E1 ) in peripheral tissue.

54
Q

Trade name of Letrozole in Management of hormone receptors positive in postmenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

Femara

55
Q

Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  1. Tamoxifen :
  2. Oopherectomy :
  3. Progestins : Medroxyprogesterone acetate & Megestrol acetate
56
Q

Significance of Tamoxifen in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

It’s not sufficient to suppress ovarian function.

57
Q

Modalities of Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

a. Surgical.
b. Radiotherapy.
c. Medical

58
Q

Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  • Significance
  • Drugs
  • Mechanism of action
59
Q

Significance of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

best modality of Oopherectomy as it is reversible

60
Q

Drugs of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  • Zoladex (Goserelin)

or

  • Decapeptyl as a monthly S.C injection
61
Q

Mechanism of action of Medical Oopherectomy in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A

LHRH agonists in a continuous manner

62
Q

Progestins in Management of hormone receptors positive in premenopausal women in Hormonal treatment in modalities of treatment of breast cancer

A
  • Medroxyprogesterone acetate

* Megestrol acetate

63
Q

Immunotherapy in modalities of treatment of breast cancer

A
  • Tissue receptors

* Drugs

64
Q

Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A
  • Her-2 receptors

* P53 receptors

65
Q

Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A
  • Definition

* Value

66
Q

Definition of Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A

It’s an epidermal growth factor protein detected on the cytoplasm of the tumour cells by immunohistochemistry.

67
Q

Value of Her-2 receptor in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A

a. Herceptin : Which is a monoclonal antibody against tumour cells is given.
b. It is an aggressive tumour )> give CAF.

68
Q

Site of Her-1 receptor

A

present on cancer colon

69
Q

P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A
  • Definition

* Value

70
Q

Definition of P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A

it is an abnormal protein synthesized by tumour cells and detected in the nucleus of the tumour cells by immunohistochemistry.

71
Q

Value of P53 receptors in Tissue receptors in Immunotherapy in modalities of treatment of breast cancer

A

It is an aggressive tumour )> give CAF.

72
Q

Drugs in Immunotherapy in modalities of treatment of breast cancer

A
  • Trastuzumab (Herceptin)
  • Imatinib
  • Bevacizumab (Avastin)
  • PARP (Poly ADP-ribosepolymerase) inhibitor
  • Rapamycin
73
Q

Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A
  • Trade name

* Mechanism of action

74
Q

Trade name of Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Herceptin

75
Q

Mechanism of action of Trastuzumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Blocks HER2/neu receptors which are +ve in 20% of cases

76
Q

Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Mechanism of action

Drug combinations

77
Q

Mechanism of action of Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer

A
  • Anti-tyrosine kinase

* Blocks growth signals transduction.

78
Q

Drug combinations of Imatinib in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

When given with Herceptin )> inc. response rate to 80%

79
Q

Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Trade name

Mechanism of action

80
Q

Trade name of Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Avastin

81
Q

Mechanism of action of Bevacizumab in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Anti-VEGF )> anti-angiogenesis

82
Q

Indication of PARP (Poly ADP-ribosepolymerase) inhibitor in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Especially in triple negative breast cancer

83
Q

Mechanism of action of Rapamycin in Drugs in Immunotherapy in modalities of treatment of breast cancer

A

Anti-mTOR

84
Q

Treatment of cancer breast stage by stage

A

Treatment of stage I cancer breast

Treatment of stage II cancer breast

Treatment of stage III cancer breast

Treatment of stage IV cancer breast

85
Q

Treatment of stage I cancer breast

A

Modalities

Ways of preserving the axilla

Indications of chemotherapy

86
Q

Modalities of Treatment of stage I cancer breast

A

A. Modified radical mastectomy OR Conservative breast surgery.

B. Radiotherapy

C. Adjuvant chemotherapy is indicated in selective cases.

D. Further management according to hormonal receptors.

E. Reconstructive breast surgery is recommended after MRM.

87
Q

Radiotherapy in Modalities of Treatment of stage I cancer breast

A

To the breast & tumour bed after conservative breast surgery

88
Q

Ways of preserving the axilla in Treatment of stage I cancer breast

A
  1. Sentinel node biopsy

2. Axillary sampling instead of axillary clearance

89
Q

Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast

A

Procedures

Results

Disadvantages

90
Q

Procedures of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast

A
  • The sentinel node is localized preoperatively by the injection of patent blue dye and /or radioisotope-labeled albumin near the tumour.
  • The marker will pass to the primary node draining the area and will be detected visually or with a handheld gamma camera,
  • Sent for frozen section histological analysis.
91
Q

Results of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast

A

In patients in whom there is no tumour involvement of the sentinel node, it is hoped that further axillary clearance can be avoided

92
Q

Disadvantages of Sentinel node biopsy in Ways of preserving the axilla in Treatment of stage I cancer breast

A

Skip lesions are thought to occur tn 3% of patients

93
Q

Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast

A
  • Levels of axillary L.N
  • Procedures
  • Disadvantages
94
Q

Levels of axillary L.N in Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast

A
  • level one below pectoralis minor
  • level two behind pectoralis minor
  • level three above pectoralis minor
95
Q

Procedures of Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast

A
  • Selective removing of level I +/- II axillary L.N

* Sending them to paraffin section histopathology

96
Q

Disadvantages of Axillary sampling instead of axillary clearance in Ways of preserving the axilla in Treatment of stage I cancer breast

A

a positive node sample must be followed by axillary irradiation or axillary clearance.

97
Q

Indications of chemotherapy in Treatment of stage I cancer breast

A
  1. Tumour size 1-2 cm. If less than 1 cm )> no micrometastasis occurs
  2. Extensive intraductal (in situ) component.
  3. Histological grade III tumours.
  4. Her-2 or p53 receptors positive.
98
Q

Treatment of stage II cancer breast

A

A. Modified radical mastectomy Or Conservative breast surgery.

B. Radiotherapy :

C.Adjuvant chemotherapy : CMF or adriamycin or CAF in aggressive tumours

D. Further management according to hormonal receptors.

E. Reconstructive breast surgery is recommended after MRM.

99
Q

Radiotherapy in Treatment of stage II cancer breast

A
  • To breast & tumour bed in conservative breast surgery.

* To supraclavicular & internal mammary L.N

100
Q

Treatment of stage III cancer breast

A

A. Palliative simple mastectomy.

B. Radiotherapy

C. Chemotherapy : CMF or adriamycin or CAF in aggressive tumours.

D. Further management according to hormonal receptors

101
Q

Aim of Palliative simple mastectomy in Treatment of stage III cancer breast

A

Removing the breast which may fungate & facilitates irradiation.

102
Q

Radiotherapy in Treatment of stage III cancer breast

A

To axilla, supraclavicular & internal mammary L.N.

103
Q

Treatment of stage IV cancer breast

A

A) as stage III cancer breast

B) Management of metastases.

104
Q

Management of metastases in Treatment of stage IV cancer breast

A

1) pleural effusion
2) pathological fracture
3) spinal cord compression
4) liver metastases
5) superior vena cava obstruction

105
Q

Management of pleural effusion in Management of metastases in Treatment of stage IV cancer breast

A

1- Intercostal tube drainage.

2- Usually responds to systemic chemotherapy.

3- If not responding, instillation of cytotoxic bleomycin through the tube is required to induce pleurodesis.

106
Q

Meaning of pleurodesis in Management of pleural effusion in Management of metastases in Treatment of stage IV cancer breast

A

fibrosis

107
Q

Management of pathological fracture in Management of metastases in Treatment of stage IV cancer breast

A
  • Internal fixation

* Radiotherapy.

108
Q

Management of spinal cord compression in Management of metastases in Treatment of stage IV cancer breast

A

Urgent spinal cord decompression with stabilization followed by radiotherapy.

109
Q

Management of liver metastases in Management of metastases in Treatment of stage IV cancer breast

A

Chemotherapy

110
Q

Management of superior vena cava obstruction in Management of metastases in Treatment of stage IV cancer breast

A

Radiotherapy is the treatment of choice.

111
Q

Follow up of breast cancer

A

1- Patients are re-examined every 3 months for the first 2 years

2- Then every 4 months for the next 3 years

3- Patients are re-examined yearly after that.

4- Mammography for the contralateral breast is done every 1 year.

112
Q

First step of breast self examination

A
  • Inspection in front of a mirror to look for any dimpling, puckering or nipple retraction
113
Q

Second step of breast self examination

A
  • Palpate both breasts, axillae, and supra-clavicular regions for the presence of a lump
    .
    This is done in a systematic manner while showering, by sliding the contralateral hand on the soaped breast.
114
Q

Third step of breast self examination

A

a repetition of the second while lying down in bed with the arm elevated.

Surgery.(General 2).Breast (8 decks)

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