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year 4 CDM 2 > Cancer: bladder and breast > Flashcards

Cancer: bladder and breast Flashcards

1
Q

Muscle Invasive Bladder Cancer (MIBC) treatment

A
  • Neoadjuvant chemotherapy: Cisplatin-based combination chemotherapy
  • Radical cystectomy: Complete surgical removal of the bladder, prostate or uterus, and regional lymph nodes. Will have to implement one of the urinary diversion options.
  • Bladder-sparing approaches: For select patients, a multimodal approach combining maximal TURBT, radiotherapy, and chemotherapy may be considered.
  • Adjuvant chemotherapy: May be considered for patients with high-risk features following cystectomy or bladder-sparing treatment. Done intravesical (into the bladder through a catheter)
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2
Q

Surgery for invasive bladder cancer

A

cystoprostatectomy or cystectomy plus hysterectomy and pelvic lymphadenectomy with creation of urostomy with ileal conduit

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3
Q

Metastatic bladder cancer treatment

A
  • First-line therapy: Platinum-based combination chemotherapy, such as gemcitabine-cisplatin or MVAC.
  • Immune checkpoint inhibitors: For patients ineligible for cisplatin or after progression: pembrolizumab, atezolizumab, or nivolumab are options.
  • Targeted therapy: For patients with specific molecular alterations (e.g., FGFR3), targeted therapies like erdafitinib may be considered.
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4
Q

Bladder cancer: urinary diversion options

A
  • Urostomy with an ileal conduit (most common): Urine drains the ileum to the skin and into a urostomy bag
  • Continent urinary diversion: creating a pouch in the abdomen patient needs to intermittently insert a catheter and drain it
  • Neobladder reconstruction: creating a new bladder from a section of the ileum
  • Ureterosigmoidostomy: urine drains through the colon. Rarely used now due to infection risk
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5
Q

Follow up badder cancer

A

regular cystoscopy within 3 months then every year or two

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6
Q

Breast cancer predisposing factors: genetic

A
  • BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovariancancer
  • Li-Fraumeni syndrome, Cowden syndrome (breast & GI cancer, thyroid disease), ataxia telengietasia and Peutz Jeghers
  • 1st degree relative premenopausal relative with breast cancer (e.g. mother)
  • P53 gene mutations
  • 10% of breast cancers are hereditary
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7
Q

Other risk factors for breast cancer (not genetic)

A
  • Nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)
  • Early menarche, late menopause
  • COCP, HRT
  • Past breast cancer
  • Not breastfeeding
  • Ionising radiation
  • Obesity, alcohol
  • Previous surgery for benign disease
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8
Q

How does hereditary breast cancer differ from normal

A
  • younger age of onset
  • frequent bilateral occurence
  • higher proportion are hormone receptor negative
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9
Q

Common breast cancer types

A
  • Invasive ductal carcinoma. This is the most common type of breast cancer.
  • Invasive lobular carcinoma: most of the remaining cases
  • Ductal carcinoma-in-situ (DCIS): more likely to become invasive than LCIS, wont cause lymph node metastasis
  • Lobular carcinoma-in-situ (LCIS)
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10
Q

Paget’s disease of the nipple

A

is an eczematoid change of the nipple associated with an underlying breast malignancy and it is present in 1-2% of patients with breast cancer. In half of these patients, it is associated with an underlying mass lesion which is an invasive carcinoma.

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11
Q

Inflammatory breast cancer

A

where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast. 1 in 10,000 cases of breast cancer. Red, hot, swollen breast. Causes peau d’orange

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12
Q

Clinical features if breast cancer

A
  • Breast lump: typically painless. Classically described as fixed, hard. Persists throughout menstrual cycle
  • Breast pain, change in breast size or shape. Lump in breast or armpit
  • Breast skin changes
  • Bloodynipple discharge
  • Inverted nipple
  • Neck or axillary mass
  • Pagets disease: eczema skin appearance, breast mass and bloody nipple discharge
  • Left breast most commonly affected: upper outer quadrant or retro areolar region
  • Most common site of metastasis: bone
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13
Q

What to look for on examination of breast cancer

A
  • Neck and axilla: lymphadenopathy
  • Nipple: is there discharge or retraction?
  • Breast tissue: is there discolouration, oedema, peau d’orange, erythema, nodules, ulceration, lack of symmetry, skin thickening?
  • Chest: signs of consolidation, nodules in skin
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14
Q

Most common metastatic sites of breast cancer and how they present

A
  • Bone: bone pain, fractures, spinal cord compress (most common)
  • Lung: plural effusion
  • Liver: hepatomegaly
  • MSK: focal tenderness in axial and peripheral skeleton due to bone involvement
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15
Q

Breast self examination

A

Recommended to perform monthly from 20. associated with better prognosis as diagnosed quicker.

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16
Q

Breast cancer epidemiology

A

most common cause of cancer for women in the UK and is the most common cause of death for 35-55. Increased risk if caucasian. Left breast more common then right

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17
Q

2WW for breast cancer

A
  • Aged 30 and over and have an unexplained breast lump with or without pain. OR
  • Aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction, other changes of concern
  • Consider: with skin changes that suggest breast cancer or aged 30 and over with an unexplained lump in the axilla
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18
Q

Triple assessment breast cancer

A
  • Clinical examination
  • Breast examination: Mammography, US, MRI
  • Fine needle aspiration or core biopsy: Needle core biopsy, Mammotome (vaccum assisted biopsy)
  • Mammography: features of malignancy include asymmetry, a mass and architectural distorsion
  • Cytological: C1-5
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19
Q

Breast cancer: staging

A
  • All staged with CXR, US of liver, bone scan
  • All suspicious lesions are explored with CT, MRI or PET-CT
  • Stage patients with tumour >5cm and >3 affected nodes (clinically palpable)
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20
Q

Imaging for boney metastasis

A
  • MRI: assess for lesion in medullary cavity of bone
  • Bone scan: initial test for boney metastasis
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21
Q

Breast cancer evaluation of masses

A
  • Cystic mass: fine needle aspiration (FNA)- if just a cyst can be aspirated to resolution, US determines if lesion is solid or cystic and if a cyst is simple or complex, Biopsy if the cysts fluid is bloody
  • Solid mass: Mammography, Fine needle aspiration, Core biopsy
  • Non palpable mass (found on mammography): Wire excision biopsy, Stereotactic guided core biopsy, US guided core biopsy, Breast MR imaging
22
Q

Breast cancer management

A
  • Surgery: either wide local excision or a mastectomy with axillary clearance. Will be offered breast reconstruction
  • Radiotherapy: in wide local excision you get whole breast radiotherapy. In mastectomy its offered for T3-T4 tumours and with 4 or more positive axillary nodes
  • Hormone therapy: If positive for hormone receptors. Tamoxifen is used for 5 years after diagnosis in pre-menopausal women. In post-menopausal women offer an aromatase inhibitor i.e. anastrozole
  • Biological therapy: trastuzumab which is sued in tumours that are HER2 positive
  • Chemotherapy: downsize primary lesions or post surgery
23
Q

Mastectomy versus wide local excision criteria

A
  • Mastectomy: multifocal tumour, central tumour, large lesion in small breast DCIS >4CM
  • Wide local excision: solitary lesion, peripheral tumour, small lesion in large breast, DCIS <4cm
24
Q

Side effects of tamoxifen, triple assessment and breast screening

A

Side effects of tamoxifen: endometrial cancer, venous thromboembolism and menopausal symptoms

Breast screening: 50-70: mammogram offered every 3 years. Afterwards can make their own appointments

Triple assessment: clinical assessment, imaging and biopsy

25
Q

How might breast cancer present

A
  • Breast lump – either painful / painless
  • Nipple changes / eczema / blood stained discharge
  • Nipple or skin tethering and indrawn
  • Axillary lymphadenopathy
  • How would you describe lump: Site, size, shape, surface, colour, consistency, contour, temperature, tethering, tenderness
26
Q

Fibroadenoma

A

Most are smooth or slightly lobulated and are usually 2-3 cm in diameter. They occur most commonly in women aged 16 to 30 years. They are very mobile – “breast mouse” and approximately 10% of fibroadenomas are multiple. Most can be observed, and excision is indicated if it is a large lump, if the patient chooses, or if the diagnosis is uncertain

27
Q

Breast cancer investigations

A
  • Mammogram: dual plane x-ray of the breast. Bilateral mammogram is offered to all patients over 40. Rarely performed under 40 due to dense breast
  • Ultrasound: any patient with breast abnormality will undergo an ultrasound regardless of age, ultrasound of abnormality and not whole breast
  • Lymph node spread: US of axilla, US guided biopsy of any abnormal nodes
  • Immunohistochemical markers: ER, PR, HER2
  • Bloods: FBC, LFT, calcium, CA 15.3
28
Q

Inflammatory breast cancer

A
  • Widespread tenderness with oedema and erythema
  • Rapid increase in breast size
  • Sensation of heaviness or burning in breast
  • Inverted nipple
  • Swollen lymph nodes
  • Skin is pitted or ridged (peau d’orange)
  • Due to build of lymph in the breast as cancer cells have blocked lymph vessels
29
Q

Duct ectasia

A

due to contraction, thickening and widening of milk ducts which become obstructed with debris and become infected. Common sign is a slit like nipple retraction, can be exaggerated in smokers. Frequently bilateral and presents with green-brown discharge, nipple inversion and pain.

30
Q

Family history BRCA

A
  • Women who have BRCA and TP53 and women with a significant family history are classified as high risk
  • Women with BRCA mutation (1 and 2) start screening at the age of 30 with yearly MRI and possibly a mammogram
  • TP53 mutation: screening at the age of 20 with yearly MRI
31
Q

Grade and size of tumour and axilla lymph node status

A
  • Grade: measure of cellular differentiation from grade 1 (well differentiated) to grade 3 (poorly differentiated)
  • Lymph nodes: 1-3 with 1 being 0 nodes affected and 3 being >3 nodes affected
  • Can be combined to give a 5 year survival probability in the Nottingham Prognostic Index (NPI): (0.2 x size) + grade + lymph node score
  • A score below 2.5 has a 93% 5-year survival, and a score of 5.5+ has a 50% 5-year survival.
  • Other prognostic factors includehistologyandstage.
32
Q

Breast cancer histology

A
  • Ductal carcinoma in situ (DCIS): is pre-cancerous and can progress to invasive cancer if left untreated
  • Lobular carcinoma in situ (LCIS): doesn’t become invasive but is a marker for developing breast cancer (lobular or ductal and in either breast). Risk isnt reduced by removing the LCIS. Require no active treatment but need annual mamographic surveillance
33
Q

Staging of breast cancer

A
  • Tumour (“T”): 0 (no evidence of cancer) to 4 (grown into chest wall/skin, or inflammatory breast cancer)
  • Node (“N”): from 0 (no evidence of spread) to 3 (4+ axillary lymph nodes)
  • Metastasis (“M”): 0 is no evidence and 1 is evidence of distant mets.
  • Can be staged from 0-4. Stage 0 refers to non-invasive breast cancers. Stages I through III describe varying tumour sizes and degrees of lymph node infiltration. Stage IV is metastatic breast cancer.
34
Q

Breast cancer Molecular subtyping

A
  • The gene expression of tumour cells: can show subtype
  • Subtype: oestrogen receptor (ER), progesterone receptor (PR) and HER2 receptor expression. Is either positive or negative
  • ER: Gene expression of theoestrogen and progesterone receptorspredicts response tohormone therapy.. It isnot prognostic. Translated into Allred’s score (0-8), a negative result is 0 or 2
  • HER2: Gene expression of HER2 predicts response to a monoclonal antibody treatment calledtrastuzumab and indicates apoorer prognosis so normally receive chemotherapy. Either positive or negative
  • A cancer that is ER-, PR- and HER2- is termed triple negative. Often PR status is omitted because its the same as ER. Usually given chemotherapy
35
Q

Treatment for different types of breast cancer

A
  • LCIS: range from observation with annual screening to bilateral prophylactic mastectomy
  • DCIS or LCIS: no role for chemo
  • Early breast cancer: wide local excision and axillary node surgery (dissection, sampling or sentinel lymph node biopsy) followed by adjuvent breast radiotherapy
36
Q

breast cancer Deciding on chemotherapy

A
  • In ER+HER- will have discussion about whether to give chemotherapy. If lots of lymph nodes involved give otherwise no
  • Oncotype Dxis a predictive test that gives the likeliness of a patientbenefitting from chemotherapy(and hormone therapy),and the likelihood ofcancer recurrence. It is carried out in some ER+ HER2- LN- patients.
37
Q

Breast cancer: key points on subtype

A
  • Molecular subtyping involves testing ER status, HER2 status, and in some patients oncotype DX
  • ER status predicts response to hormone therapy
  • HER2 predicts response to trastuzumab and has a poor prognosis
  • HER2+ and triple negative cancers are given chemotherapy
  • TNM stage and sometimes oncotype DX determine whether chemotherapy is necessary in ER+ HER2- cases
38
Q

Breast cancer: summary of treatment options

A
  • Local: surgery, radiotherapy
  • Systemic treatments: chemotherapy, Hormone therapy
39
Q

Breast cancer: surgery

A
  • Usually the first treatment patients receive, therapy received after surgery is adjuvant and before is neo-adjuvant
  • Breast surgery is either breast conserving or a mastectomy with axillary clearance.
  • Side effects of axillary clearance: chronic lymphodema due to impaired lymphatic drainage
  • Breast conserving is almost always offered with radiotherapy
  • Mastectomies can be followed with reconstructive surgery, either in the same surgery (“immediate reconstruction”) or at a later time (“delayed reconstruction”)
40
Q

Breast cancer: axillary surgery

A
  • Axillary clearance, sentinel node biopsy or omitted. Axilla surgery gives information about local recurrence, does not affect survival
  • Axillary clearance: ≥4 lymph nodes affected
  • 1-3 lymph nodes: axillary clearance or targeted axillary dissection
  • If ultrasound clear use sentinal node biopsy
  • In DCIS axillary surgery is omitted
  • Don’t take blood from the same arm axillary clearance surgery has been performed on can cause Lymphoedema
41
Q

Breast cancer: radiotherapy

A
  • Reduces risk of recurrence less impact on survival
  • Given to breast, chest wall and/or lymph nodes
  • Can be used to treat distant symptomatic metastases in a palliative setting, e.g. symptomatic bone metastases.
  • Carries out 6 weeks after chemotherapy or surgery.
  • Risks: rib fracture, sunburn, blistering, lung fibrosis, osteonecrosis
  • Contraindications: connective tissue disorder with significant vasculitis, prior radiotherapy, TP53 mutation
42
Q

When to give radiotherapy in breast cancer

A
  • Mandatory in breast conservation surgery, can be an alternative to axilla surgery
  • Should be offered post mastectomy if: tumours >5cm, tumours deep in the breast where surgical clearance is <3mm, 4 or more lymph node metastasis
43
Q

Breast cancer systemic treatment: Hormone therapy

A
  • Anyone ER+ gets it
  • Hormone therapy prevents the binding of oestrogen to oestrogen receptors, inhibiting ER+ tumour cell proliferation
  • In premenopausal women use Tamoxifen. Its a SERM that blocks oestrogen receptors in the breast tissue. May be offered a LHRH analogue. Protects against osteoporosis, increases endometrial cancer risk
  • In postmenopausal women use aromatase inhibitors. They block non-ovarian sources of oestrogen like fat cells. Reduces recurrence
  • Usually started after all other treatment: normally a tablet taken OD for 5 years, can be used neo-adjuvant or in very elderly instead of surgery ‘primary hormone therapy’
44
Q

Breast cancer systemic treatment chemotherapy

A
  • Usually given as adjuvant therapy to reduce recurrence and improve survival. Can be neo-adjuvant
  • Normally have 8 cycles
  • Regime options: FEC(fluorouracil, epirubicin, and cyclophosphamide) andEC(epirubicin and cyclophosphamide).
  • Taxanes (i.e. docetaxel) can be added in patients with poorer prognosis i.e. node positive patients. Can cause neuropathy but reduce recurrence
45
Q

Complications of chemotherapy

A
  • Side effects: nausea, weight loss, fatigue, change to skin and nails, immunosuppression, easy bleeding and bruising
  • Side effects: deterioration in kidney function, thrombosis
  • Severe complications: cardiotoxicity, neutropenic sepsis, death, infertility, secondary malignancy
46
Q

When to offer adjuvent chemo

A
  • If higher risk of recurrence
  • Tumour >1cm
  • ER-
  • Involved axillary lymph nodes
47
Q

What targeted treatment is used for HER2+ breast cancer

A
  • monoclonal antibodies that target HER2, such as: trastuzumab (Herceptin), pertuzumab (Perjeta)
  • tyrosine kinase inhibitors such as:- neratinib (Nerlynx)
48
Q

Treatment for metastatic breast cancer

A
  • Radiotherapy for painful bone metastasis
  • Aromatase inhibitors
  • ER- disease: combination chemo
  • Trastuzumab: for relapsed HER2+ disease
  • Bisphosphonates in bone metastasis
49
Q

Preventing breast cancer

A
  • Prophylactic mastectomy
  • Ovarian ablation: makes patient post-menopausal reducing breast cancer risk
  • Tamoxifen: pre-menopausal
  • Aromatase inhibitors: post menopausal
  • Increased surveillance: annual mammogram for 5 years
50
Q

Breast cancer complications

A
  • Local invasion: lymphoedema, pleural effusion, ascites
  • Bone metastasis: bone, liver, lung, brain. Spinal cord compression
  • Non-metastatic: Hypercalcaemia

year 4 CDM 2 (39 decks)

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