OPB Flashcards
what age are fibroadenomas seen in
20-30
what are are cyst seen in
30-40
main 2 causes of breast infection
smoking
lactation
what is slit like nipple inversion signify
usually benign
often nipple can be fully everted with manipulation
presentation of nipple eczema
often starts on the areola and spreads
red scaly nipples
paget’s disease presentation
-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
ages and benign breast disease presentation 20-30
fibroadenoma
juvenile hypertrophy
25-35 breast benign disease
cyclical mastalgia
galactocele
papilloma duct discharge
> 40 benign breast disease
cysts
periductal mastitis
sclerosing lesions, hyperplasia, atypia
duct ectasia
pathology of breast cyst
fluid filled and benign
usually pre-menopausal
distended involuted lobules
presentation of breast cyst
- 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
diagnosis of breast cyst
USS/ mammogram
management of first breast cyst
-refer for exclusion of malignancy -urgently if >30
management of past hx of breast cyst -
aspiration
which signs on breast cyst aspiration need referring on
- blood stained
- cyst refills
- residual lump after aspiration / solid areas (intra-cystic papillary carcinoma?)
what is a galactocele
milk containing cyst which arise during pregnancy
management of a new lump in pregnancy
refer
what is a radical scar/ complex sclerosing lesion on the breast
- scar arising in breast but without any previous trauma or surgery
- cause unknown- inflammation
management of breast radical scar
-1 in 5 have cancer
-need to refer
often excision
assoc. of breast radical scar
atypical duct hyperplasia
risks of papilloma
-can cause breast cancer
what is a breast papilloma
- wart like lump that forms in the duct if intraductal
- develops inside the lumen
presentation of breast papilloma
- wart like lump in the duct
- nipple discharge which can be blood stained
management of breast papilloma
refer for excision
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
classification of fibroadenoma
-common
giant >5cm
juvenile- teenage girls
presentation of fibroadenomas
-mobile well defined lump
-non tender
-highly mobile
-firm or rubbery
smooth mobile
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
diff dx of fibroadenoma
phyllodes tumour so need core biopsy
prognosis of fibroadenoma
1/3 regress alone
1/3 stay same
1/3 grow
vv rare to become cancerous
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
management of fat necrosis of breast
- refer for breast triple assessment
- always urgent referral
- once dx confirmed no treatment needed
mondor’s disease of breast is…
inflammation of the superficial veins of the breast
benign thrombophlebitis of vein and axilla
presentation of mondor’s disease
- red pain and cord like thickening of vein
- self limiting
management of Mondor’s disease
- triple assesment - referral
- rarely assoc. to malignancy
-treatment NSAID
Hydranitis suppurativa what is it
-young patients
acne on arm pits
cause of hydranitis suppurativa
-chronic inflammation of axillary apocrine sweat glands
management of hydranitis suppurativa
antibiotics, drain abscesses, excision
complications of hydranitis suppurativa
recurrent infection
abscess
scar formation
what age does hydranitis suppurativa tend to stop
35
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
what is poland syndrome
absence of chest wall
dont develop pectoralis major and breast and chest wall
reconstructive procedure
what is gigantomastia
breast tissue becomes very inflamed red and grows rapidly
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
who gets duct ectasia
often >50 around menopause
symptoms of duct ectasia
- nipple discharge- often green
- retraction
- inverted nipples
- doughy palpable mass
- discharge cheesy/ white
- slit like nipple retraction
management of duct ectasia
-refer for confirmation of dx
conservative management or
surgical with excision of total duct
what is phyllodes tumour
- hypercellular stroma with atypia
- large and fast growing
- arise from periductal stromal cells of the breast
differentiating phyllodes and fibroadenomas
phyllodes usually larger and older age group
30-50 yrs
behaviour of phyllodes tumour
-varies
benign 70%, malignant 5% or borderline 25%
-malignant potential
-can have an infiltrative margin especially in aggressive forms
management of phyllodes tumour
need referral for triple assessment
wide local excision with clear margin of normal breast tissue
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
when to refer mastitis
- if not settling after one course of antibiotics
- refer for abscess
- breast inflammation in >35 even if settling
management of mastitis
-antibiotics
drain abscess under la
lactational infection cause
- usually in early weeks post-partum
- poor latch, nipple trauma, milk stasis
management of lactational infection
- treat early with antibiotics- flucoxacillin
- continue feeding as avoid milk stasis
cause of non-lactational infection
-mostly due to smoking
periductal infection
often chronic and difficult to treat
what is peri-ductal mastitis
-inflammation of ducts below nipples
who gets peri-ductal mastitis
smokers
presentation of peri-ductal mastitis
-repeated infection +/- abscess formation at edge of areola and can get fistula
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
sebaceous cyst on breast management
- treat as elsewhere
- drain if abscess
- consider formal excision of cyst wall when acute resolves
main cause of breast abscess in lactation
staph aureus
causes of breast absceses
lactation infection
periductal mastitis-peri-areolar
epidermoid cyst, hidraenitis
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
complication of peri-ductal mastitis
mammary duct fistula
management of mammary duct fistula
-excision of fistula and total duct excision
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
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
paget’s disease management
refer urgently
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
paget’s of nipple is assoc. too
invasive ductal carcinoma
fibroadenosis pressentation
-most common middle age
lumpy breasts which can be painful
symptoms may worsen prior to mensturation
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
commonest cause of blood nipple discharge in young women
intraductal papilloma
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
Females < 30 years with a non-tender, discrete and mobile lump =
fibroadenoma
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
inidcations for antibiotics for lactational mastitis
1st line= continue breast feeding
give antibiotics if
- culture positive
- nipple fissure present
- systemic symptoms
- no improvement 12-24hrs of effective milk removal
. 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
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
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
what does a triple assessment involve
- clinical hx and exam
- imaging- USS or mammogram
- pathology- FNA, core biopsy
breast awareness 5 point code
- know what is normal for you
- know what changes to look and feel for you
- look and feel
- report any changes to GP without delay
- attend for routine breast screening if >50
lump features that require an urgent referral 7
- any new discrete hard lump in patients over 30
- any age with phx of breast cancer presenting with a further lump or suspcisious symptoms
- asymmetrical nodularity that persists after period in patients over 35
- aged >35 with discrete lump that persists after next period or presents after menopause
- unilateral isolated axillary lymph node in women persisting at review after 2-3 weeks
- recurrent lump at site of previously aspirated cyst
- aged <35yrs with a lump that enlarges or is fixed/ hard in whom there are other reasons for concerns such as hx
nipple changes that require an urgent referral 3
- unilateral eczematous skin or nipple changes that don’t respond to topical treatment
- nipple distortion of recent onset eg retraction
- spontaneous unilateral blood nipple discharge
skin changes that require an urgent referral
- skin tethering or dimpling
- fixation
- ulceration or peau d’orange
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
where do most breast cancer arise from
terminal duct lobular unit
breast symptoms
lump nipple discharge retraction skin changes abscess/ infection pain gynaecomastia
breast lump causes
breast cancer fibroadenoma cyst duct ectasia fat necrosis phyllodes tumour
signs of malignancy of breast on mammogram
high density lesion microcalcification irregular margin distortion asymmetry lymphadenopathy
signs of malignancy on USS
irregualr margin posterior acoustic shadowing distorition heterogenous echo tecture echogenic halo TALLER THAN WIDE vascularity
signs of fibroadenoma on mamogram
wider than taller- suggest more benign
indications for MRI
good for implants, occult lesions and extent of disease
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
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
breast pain 2 causes
- cyclical breast pain-true breast pain usually bilateral
2. MSK usually unilateral
mastalgia causes
physiological duct ectaasia breast cancer sclerosing adenosis mastitis abscess
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
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
non cyclical breast pain means
continuous or intermittent pain but not related to menstrual cycle
causes of non cyclical brest pain
- well localised= ill fitting bras, cyst, abscess, cancer
- more generalised= referred pain eg nerve root
bilateral nipple discharge causes
central
-pituitary adenoma- galactorrhoea
causes of nipple discharge
-pregnancy
-duct ectasia
inflammation
papilloma
DCIS/ invasive cancer
endocrine
mamary fistulas
joggers nipple
medications
drugs that cause nipple discharge
haloperidol
methyldopa
phenothiazines
red flags nipple discharge
unilateral
blood stained
single duct (except papilloma-although can sometimes)
management of nipple discharge
triple assessment explain and re-assure microdohectomy total duct excision specific intervention
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
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
presentation of gynaecomastia
benign enlargement of the male breast resulting from the glandular component of the breast
- rubbery or firm mass
- ususally bilateral
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
management gynaecomastia
- treat underlying cause
- reassurance of innocent nature of condition and resolves spontaneously
- endocrine refer to endocrinologist
- no inx for puberty gynaecomastia
medical treatment for gynaecomastia
for idiopathic or residual gynaecomastia
- tamoxifen if justified for 6 months
- aromatase inhibitors older men
- surgery is rare
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
when to refer nipple eczema
if no response to topical treatment
choice of breast imaging >40
use mammogram
need two views
two views needed on mammogram
mediolateral oblique and
cranial caudal projection
choice of breast imaging <40
USS if focal breast problem- 1st line
adjunct mammography where malignancy is suspected
choice of breast imaging in male <40
USS
choice of breast imaging in males >40
mammography
imaging choice if implants
mammography >40 plus USS
uss <40
may also need MRI to exclude malignancy or implant rupture
USS indications
palpable lump
not in pain
-examine axillary lymph nodes
useful for
- core biopsy or aspiration
- detects solid vs fluid filled
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
implant rupture imaging
USS or MRI
mammography indications
breast abnormalities >40
national screening program
early screening if fhx
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
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
why is mammography used for breast screening
because it can also detect micro-calcification in situ disease
what is tomosynthesis
3D mammography
additional information of core biopsy
tells you about grade, ER PR and HER2 status
additional information of core biopsy
tells you about grade, ER PR and HER2 status
breast cancer epidemiology
most common cancer in UK women
second commonest overall
lifetime risk of breast cancer
1 in 8
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
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?
diet and breast cancer
high in fat
low in beta carotene
folate vit a and c low
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
genes invovled in breast cancer
5% are BRCA BRCA1 BRCA2 PTEN COWDEN MSH1 or MSH2 in HNPCC p53 syndromes
penetrance and assoc. cancers of BRCA 1
80% penetrance
ovarian, colon, prostate
BRCA2 penetrance and assoc. cancer
50% penetrance
male relatives
also ovarian cancer
management of BRCA breast cancer
bilateral mastectomy
MRI screening annually
prevent Tamoxifen in ER positive fhx
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
breast screening for moderate risk
begins with yearly mammography at 40
breast screening for high risk
begins with yearly mammography at 30
breast screening program for BRCA 1 or 2
yearly MRI and mammography from age 30
breast screening program for Tp53 faulty gene
yearly MRI from 20
breast cancer pathology
- commoner in the left breast
- 50% in upper outer quadrant
most common breast cancer type
ductal carcinoma
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
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
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
ductal carcinoma in situ % of breast cancers
90%
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
inx for DCIS
-can be seen on mammography as microcalcification
impalpable so usually only seen on screening
core biopsy
management of DCIS
surgical: all diseased tissue must be excised with clear histological margins
- radiotherapy in high grade DCIS
invasive ductal carcinoma % of breast cancer
75%
how does invasive cancer spread
tumour invades through the lymphatics
signs of locally advanced and metastatic breast cancer
peau d orange
skin inflammation
skin involvement
chest wall involvement
rare
systemic treatment prior to surgery
inflammatory breast cancer presentation
need to always consider as a cause of mastitis
so if mastitis doesnt improve with antibitiocs then refer urgently
management of inflammatory breast cancer
-aggressive cancer
-triple assessment
chemo
surgical
radiotherapy
receptors for breast cancer
ER- estrogen receptors
PR-progesterone receptors
HER2-human epidermal growth factor receptor 2
ER positive breast cancer is
expressed in 60-70% of breast cancers
dependent on oestrogen to control tumour growth
better prognosis
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
Ki-67 assoc. to breast cancer
marker of cell proliferation
assoc. to better response to neo-adjuvant chemo but overall prognosis is poorer
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
diagnosis breast cancer
triple assessment mammo or USS MRI FNAC or core vacuum assisted biopsy USS of axilla blood test
early breast cancer staging inx
-blood test- LFT and calcium
x-ray chest
USS liver
sentinel lymph node biopsy
locally advanced breast cancer staging
-CT scan MRI bone scan liver USS blood tests sentinel lymph node biopsy
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
management if sentinel lymph node biopsy is positive
need definitive axillary surgery and clearance
risks of axillary clearance
lymphoedema
mets of breast cancer
liver lung bone brain
axilla
non invasive insitu managemetn options
- simple mastectomy
- wide excision alone or breast conserving surgery
- wide excision and post-op radiotherapy
when would a mastectomy be indicated over a wide local excision
mastectomy if
- central tumour
- multifocal tumour
- large lesion in small breast
- DCIS >4cm
LCIS management
close monitoring
low grade DCIS management
wide local excision
high grade DCIS management
DCIS in two or more quadrants
mastectomy (multifocal) and post-op radiotherapy
DCIS in males management
mastectomy
recurrence DCIS
mastectomy
early breast cancer management
breast conserving surgery- lumpectomy
and SNLB
+/- axillary clearance
locally advanced breast cancer management
neo-adjuvant chemotherapy
mastectomy or lumpectomy
axillary clearance
advanced breast cancer management
salvage mastectomy with or without reconstruction
axillary clearance
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
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
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
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
mastectomy and reconstruction
generally offered
-primary reconstruction may be avoided if chest wall radiotherapy likely to be indicated
if not using SLNB how many nodes must be sampled
at least 4
types of breast reconstruction
-either as immediate or delayed
- implant/ expander
- latissimus dorsi muscle flap
- free tissue transfer eg from stomach TRAM/DIEP flap
radiotherapy of whole breast indications
- all patients after breast conserving surgery
- no lymph node mets in an adequate axillary node sample of 4 nodes
- > 4 nodes positive
- women <50 at surgery
- invasive disease with inadequate excision margins unsuitable for re-excision
- conserved breast unsuitable for excision
- T4 disease at presentation
radiotherapy for chest wall indications
-after mastectomy in some cases
tumour size >5cm, 4 or more involved nodes and involved resection margins
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
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
what chemo is given for breast cancer
cyclophos
methotrexate
5 fu
how is chemo given for breast cancer
-can be neo-adjuvant eg to shrink down for surgery
to do breast conserving
- or adjuvant
medical treatments given in breast cancer
-hormone, tamoxifen, aromastase
-chemotherapy
-biological
-bisphosphonates
radiotherapy
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
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
determine post-menopausal >54 and amenorrhoeic for 12 months
no need to check
if patient has PV bleed then stop
prognostic factors of breast cancer
lymph node status tumour size grade I-III lymphatic/ vascular biological factors
breast cancer follow up yr1
clinical and mammogram
check hx
breast cancer follow up yr 2-4
mammogram only
breast cancer follow up yr 5
-clinical exam
mammogram
if on endocrine therapy consider switching, extending or stoping
breast cancer follow up yr 6-10
mammogram only with clinic appointment yr 10 if on endocrine treatment
HER2+ additioanl management
- chemotherapy-docetexal, paclitaxel
- Herceptin -transtuzumab
ER+ additional management pre menopause and men
-tamoxifen
goserelin
oophorectomy
ER + additional management post menopausal
aromatase inhibitors
fulvestrant
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)
indications for bisphosphonates for breast cancer
node positive invasive breast cancer
reduces risk of bony mets in later life
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
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
administration of tamoxifen
oral
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
contrainidcations to tamoxifen
pregnancy
hypersensitivity
concurrent anastrozole therapy
personal hx or fhx of VTE
drug interactions of tamoxifen
anastrazole
hormonal therapy
warfarin- enhances
cyp450
aromatase inhibitors example
anastrozole,-type 1 oral steroidal
letrozole- type 2
exemestane
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
action of aromatase inhibitors
in post-menopausal women peripherlal oestrogen synthesis from aromatase in adipose tissue
-aromatisation blocking reduce oestrogen
administration of aromatase
oral
monitoring on aromatase
need DEXA scan due to risk of osteoporosis
SE of aromatase
alopecia hot flushes tired muscle pain dry skin hair thinning sweats reduced appetite arthritis insomnia osteoporosis
contraindications to aromatase
pregnancy pre-menopausal breast feeding use with caution in liver failure avoid if CrCL <20 hypersensitivity to lactose
drug interactions aromatase
dont give with tamoxifen or oestrogen containing therapies
goserelin zoladex indications
prostate cancer
oestrogen receptor positive breast cancer
endometriosis
fibroids
action of Goserelin
GnRH analogue initial stimulation of GnRh then donw regulation of gonadotrophin releasing hormone receptors reduce FSH and LH reduce oestrogen
administration of goserelin
SC
implant
contraindications of goserelin
undx vaginal bleeding
pregnancy
breast feeding
side effects goserelin
prolong QT greater risk cord compression alopecia arthralgia bone pain breast abnormalities depresssion glucose tolerance gynaecomastia hypercalcaemia
Herceptin is
transtuzumab
herceptin indication
breast cancer with HER2 positive
gastric cancer HER2
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
herceptin mechanism of action
monoclonal antibody targets HER2 to prevent it being overexpressed
administraction herceptin
IV
SC
Contraindications to herceptin
severe dyspnoea at rest
caution in heart problems
avoid in pregnancy and breast feeding
SE herceptin
alopecia anaemia angioedema and dyspnoea arthritis, asthma GI problems infusion reactions
monitoring needed for Herceptin
cardiotoxicity
drug interactions of herceptin
vaccines
drugs cardiotoxic
Imatinib action
tyrosine kinase inhibitor
imatinib indications
haem malignancies
-CML
ALL
GIST tumours
dermatofibrosarcoma protuberans
interactions SE of imatinib
infection risk alopecia anaemia chills and constipation cough nandv photosensitivity thrombocytopaenia
administration imatinib
oral
CI imatinib
pregnnacy
breast feeding
monitoring imatinib
GI
bloods
growth in children
capecitabine indications
colon cancer
gastric cancer
breast cancer
action of capecitabine
metabolised to fluorouracil in the liver which is a thymidylate synthase inhibitor
chemo medicaiton
CI to capecitabine
dihydropyrimidine dehydrogenase deficiency avoid in pregnancy discontinue breast feeding avoid if CrCL <30 severe neutropaenia lactose intolerant avoid live vaccines
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
monitoring for capecitabine
calcium
eyes
skin
hand and foot
drug interactions capecitabine
warfarin
sorivudine
phenytoin
calcium folinate
rituximab indications
non hodgkin lymphoma
CLL
pemphigus vulgaris
action rituximab
monoclonal antibody to B cells
administration rituximab
IV
SC
CI rituximab
cardiac
pregnnacy
breast feeding
live vaccines
SE rituximab
alopecia anaemia conjunctivitis GI depression increased risk of infection MI neutropaenia pain thrombocytopaenia tumour lysis syndrome infusion related se
ZOLEDRONIC acid indication
hypercalcaemia of malginancy
bone mets
node positive breast cancer
steroid induced osteoporosis
action of zoledronic acid
binds to hydroxyapatite crystals in bone
disrupts osteoclasts
prevent break down
interactions of zoledronic acid
calcium
diuretics
gentamycin
toxicity signs zoledronic acid
amount of urine, muscle spasms weakness, mood, heart beat seizures
monitoring zoledronic acid
-blood test
must be on birth control
inx of prostate cancer
PSA DRE MRI prostate TRUS transrectal biopsy gleason score
localised prostate cancer treatment options
observation-watchful waiting
active surveillance
radiotherapy and bracytherapy
surgical
complications prostate cancer management
- surgery- impotence/ incontinence
- radiation- proctitis, cystitis
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
colorectal cancer inx
bloods sigmoidoscopy biopsy barium enema colonoscopy USS MRI CT
FAP
familial adenomatous polyposis
autosomal dominant
lots of polyps
APC andeomatous polyposis colii gene
HNPCC hereditary non polyposis colorectal carcinoma
autosomal dominant
mutation MLH1 MSH2 DNA mismatch repair gene so get microsatellite instability
neo-adjuvant management of rectal cancer
-radiotherapy
chemotherapy
management of GI cancers
-rectal only get neo-adjuvant
surgical
-adjuvant chemotherapy - capecitabine or oxaliplatin
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
management of acute skin toxicities radiotherapy
aqueous cream
prophylactic use of bethamethasone- topical steroid
minimising toxicities of radiotherapy
positioning
cardiac shielding eg MLC
breathing manoeuvres
what is bracytherapy
sealed radiation source is placed inside or next to the area requiring treatment
LUNG CANCER presentation
asymptomatic invasive symptoms eg SVCO dysphagia horner airway symptoms systemic finger clubbing HPOA
where does lung cancer spread
lumph nodes adrenals pleura liver skin bones brain
types of lung cancer
SCLC 15%
NSCLC
-adenocarcinoma
squamous
large cell
adenocarcinoma lung
- more common type in non-smokers
- overall most common
large cell lung cancer
peripheral
anaplastic, poorly differentiated
poor prognosis
squamous cell lung cancer
-slower growing paraneoplastic -hypercalcaemia- ectopic PTH -finger clubbing -hyperthyrodisim produces TSH HPOA central
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
mesothelioma lung
linked to asbestos
INX for lung cancer
- CXR
- CT CA with contrast
- tissue collection
- bronchoscopy for central lesions
- EBUS
- CT guided percutaneous tranthroacic FNA for peripheral lesions - CT PET if surgical considered stages 1-3
small cell lung cancer management
usually metastatic by dx
can resect if early
chemo cisplatin and radiotherapy
SACT
non small cell management
- surgery and chemoradiotherapy
- tyrosine kinase inhibitor for eGFR mutation
causes of pulmonary mets
renal breast colorectal bladder remember big colourful balls
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
main biomarker for ovarian cancer
ca125
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
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
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)
presentation of neutropaenic sepsis
temperature >37.5 or <36.5
-not always
symptoms
-sspsi
unwell
patient at risk especially 7-21 days post SACT
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
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
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
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
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
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
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
main causes of malginant cord compression
-breast
lung
prostate
myeloma
types of cord compression
complete compression
anterior compression- pain and temp
-posterior- vibration and position
lateral- brown sequard pain and temp
dx of cord compression
URGENT MRI OF WHOLE SPINE
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
treatment of malignant cord compress acute
-lie flat steroids- immediate dexamethasone plus PPI cover analgesia thromboprophylaxis prompt physio ensure spine stable
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
radicular pain plus active or recent cancer is
malignant cord compression until determined otherwise
SVCO is
obstruction of blood flow through the SVC
due to compression, invasion or intra-luminal thrombus in SVC
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
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
assessment SVCO
- extent
- any evidence of malginancy elsewhere eg lymphs, collapsed lung
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
cause of obstruction SVCO
within
- clot
- foreign body
- tumour eg renal cancer
extrinisc compression
inx SVCO
usually not an emergency so inx -CXR-widened mediastinum -venogram CT chest bloods mass-biopsy
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
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
definition of malignant hypercalcaemia
hypercalcaemia >2.65 on two occasions following adjustment for serum albumin concentration
-urgent intervention needed if >3
mechanisms of malignant hypercalcaemia
- osteolytic measures due to bone mets-release protein that increase osteoclast activation
- circualting PTHrP or calcitriol released
tumours that release PTHrP
squamous carcinomas of lungs head and neck renal bladder ovarian
tumours that release calcitriol
lymphoma-hodgkin’s
inx for tumour PTHrP findings
low vit D-calcitriol
high PTHrP
low PTH
inx for osteolytic measure tumour findings
low PTH
low calcitriol or normal
low PTHrP
calcitonin function
meant to reduce calcium re-uptake and increase calcium bone deposition when calcium is high
severity hypercalcaemia
mild=2.65-3
mod 3.01-3.40
severe >3.40
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
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
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
management <3 calcium
no active treatment needed
avoid dehydration and medications
management 3-3.5
-generally no active treatment unless symptomatic or acute
symptomatic- fluid replacement 0.9% sodium chloride
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
SE of bisphosphonates
GI upset flu like symptoms exacerbation of metastatic bone pain ostenecrosis of the jaw hypocalcaemia
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
malignant pericardial effusion causes
-thoracic malignancies such as lung cancer, mesothelioma or metastatic disease
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
inx for malignant pericardial effusion
ECG
CXR
ECHO confirm
aspiration
CXR signs of pericardial effusion
- increased cardiothoracic ratio
enlarged globular heart
management of pericardial effusion
-drain by needle under radiological control
-surgical procedure of pericardial window formation
treat underlying cancer
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
patient with large volume malignant disease develops acute renal failure
tumour lysis sundrome
which tumours are assoc. to tumour lysis
-poorly differentiated lymphomas
leukaemias
germ cell tumours
breast myeloma
-chemo sensitive tumours
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
metabolic abnormalities of tumour lysis syndrome and presentation
- hyperuricaemia
- release of nucleic acids metabolised to uric acid
- then depositis in renal tubules and causes acute uric acid nephropathy
- oliguric ARF - hyperphosphateamia
- 2ndary to release of intra-cellular phosphate
- malignant cells have higher phosphate
- precipitate with calcium deposits in kidney- ARF - hyperkalaemia
- exacerbated by deteriorating renal function
- cardiac- ECG tall t, loss p, wide qrs, sine wave - hypocalcaemia / hypomagnesia
- secondary to increase phosphate
- muscle weakness and tetany - Acute renal failure
- uric acid and phosphate deposit - metabolic acidosis
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
preventing tumour lysis syndrome
- optimise renal function before and during treatment
- relieve any obstruction
- correct any existing electrolyte abnormalities
- ensure adequate fluid replacement
- (mannitol) - if low risk- absence of pre-treatment hyperiuricaemia
- allopurinol can be given pre-chemo for 48 hrs to decrease incidence of post-treatment hyperuric - 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
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
main cancer pains
bone nerve compression visceral pain muscle spasm soft tissue pain post-op pain neuropathy back pain capsulitis shoulder constipation
neuropathic pain cause
nerve damage
burning, sharp, pins and needles
allodynia may occur
can be localised to dermatomes
WHO analgesic ladder
- non opioid
-paracetamol
NSAID - mild opioid eg codeine
- strong opioid for moderate to severe pain
eg morphine
SE opioids
DESIGNER dry mouth euthoria sedation itch GI nausea eyes resp depression
opioid toxicity
confusion drowsiness myooclonic jerk hallucinations peripheral shadows
withdrawal symptoms of opioids
n and v
diarrhoea
depression
strong opioids
morphine diamorphine fentanyl oxycodone alfentanil methadone
weak opioids
codeine co-codamol dihydrocodeine tramadol buprenorphine
codeine
metabolised to morphine at liver
avoid in CKD 4 and 5
dihydrocodeine
similar to codeine
metabolised in liver
avoid in CKD 4 and 5
tramadol
also an opioid but different chemically renal excreted use with caution in CKD 4 and 5 CI if on MAOI or epilepsy
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
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
diamorphine
parenteral SC and pump highly soluble use for high dose SC breakthrough avoid in CKD 4 and 5
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
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
opioid toxicity
precipitated by dose escalation, renal impairment, sepsis, electrolyte abnormalities, drug interactions
presentation opioid toxicity
persistent sedation vivid dreams, hallucinations, myoclonus jerking confusion delirium muscle twitch
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
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
pain management
mild pain
- paracetamol/ NSAID
- weak opioid- codeine, dyhydrocodeine, buprenorphine, tramadol
moderate to severe pain
- morphine and stop any weak opiods
- nerve blocks, epidurals,
anorexia in cancer causes
-neurohumoral multifactoial metabolic reduced fuel supply accelerated metabolism
causes cancer related fatigue
depression anaemia cancer rx tumour bulk cytokine release
delirium definition
disturbed consciousness and inattention with cognitive impairment
delirium is often reversible
fluctuating state of lucid points with confusion, hallucination, agitation
three types delirium
hyperactive
hypoactive
mixed
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
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
