Part 4

Presentation of breast cancer

Breast lump 

****** discharge and / or inversion 

Eythema, peau d'orange, ****** ulcer / eczma 

Skin dimpling / deforrmity / puckering 

Axillary mass 

lymphoedema 

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Diagnostic score for breast cancer

Physical exam = P/E 

Mammography = M 

US = U 

Cytology = C 

Core biopsies = B 

1 = normal 

2 = benign 

3 = intermediate 

4 = suspicious of malignancy 

5 = malignancy 

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Classic lobular carcinoma in situ (LCIS) / lobular

Not considered breast cancer 

But a marker of increased risk 

(2)

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Ductal carcinoma in situ (DCIS), pleomorphic LCIS

Considered a cancer 

Remain in the basement membrane of the tubules of the breast 

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Tamoxifen

Drug given to a patient who is oestrogen receptor positive 

Reduces risk of recurrence so can be continued after remission 

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1 and 2 = early, 3 = locally advanced

Stage 1 and 2 breast cancer = 

Stage 3 = 

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Inflammatory breast cancer

A form of locally advanced breast cancer 

Most aggressive form 

Presents as swelling, tenderness and redness 

Sentinel lymph node biopsy is contraindicated 

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Herceptin (trastuzumab)

Treatment for HER-2 receptor (EGFR) +ve breast cancer 

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TP53

Breast cancer = 80-90% 

High risk of sarcoma 

High risk of childhood leukaemia 

Adrenal cancer 

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Lung Cancer

Clinical features 

Most common:

Anorexia and weight loss 

Cough, dyspnea 

Supraclavicular LNs 

Others: 

Chest pain, haemoptysis 

Hoarseness, dysphagia 

Bone pain, clubbing 

Neurological manifestations 

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Small cell lung carcinoma

10-15% of lung cancers 

Predominantly smokers 

More aggressive form 

Rarely resectable (<1%) therefore surgery is ineffectibe 

Chemosensitive but prone to recurrence and resistance to chemotherapy 

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NSCLC

80-85% of lung cancers 

Adenocarcinoma 

Squamous cell carcinoma 

Large cell 

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Adenocarcinoma

Most common type of cancer in NSCLC 

Due to EGFR mutations 

K-ras 

and more 

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5, 8 and 9

What numbered lymph nodes are missed in endobronchial USS 

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Indications for surgery

Stage I and II (some with IIIa)

Adequate lung function (FEV1 >60% - should allow pneumonectomy) 

No significant co-morbidities 

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Chemotherapy in NSCLC

Chemotherapy in what cancer? 

Platinum + new agents (gemcitabine) 

Chemoradiotherapy in N2/N3 disease + immune therapy 

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EGFR

Overexpressed in 60% of NSCLC 

Inhibition especially effective in adenocarcinomas 

Response correlates with mutation in the gene 

Resistance common 

Most mutations are exon-19 short in frame deletions, or exon-21 point mutations 

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Ab that blocks PD-1

Pembrolizumab

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Stage IV squamous cell LC

Treat with:

Pembrolizumab 

Platinum chemo 

Nivolumab 

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Stage IV non-squamous cell LC without mutations

Treat with:

Platinum chemo 

Nivolumab 

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Non-SCC with EGFR or ALK rearranged

Treat with 

Tyrosine kinase inhibitors (for EGFR)

Platinum chemo 

Nivolumab 

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Asthma

Diagnose:

Both sides of chest expanding - Yes

Breath sounds same on both sides - Yes 

Lung resonant on both sides - Yes 

Wheezes from narrow airways - Yes 

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Severe asthma attack

Breathless at rest, speech in words or phrases 

RR >25 

Pulse >110

Loud wheeze 

<33% predicted PERF/FEV1

PaCO2 >40mmHg

PaO2 < 60mmHg 

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Life threatening asthma attack

Cyanosed at rest, too breathless to speak 

RR > 25 

Pulse >110 or may be bradycardic 

May have a quiet chest 

<20% predicted PERF/FEV1

PaCO2 >45mmHg 

PaO2 <60mmHg despite O2 therapy 

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Types of hypersensitivity

Type 1 = Allergy 

Mediated by IgE mast cells 

Type 2 = Antibody mediated - complement mediated 

Triggered by complexes of Ab-Ag (IgM,IgG) against cell surface / ECM 

Type 3 = Immune complex mediated 

Soluble immune complexes, IgM and IgG 

Type 4 = Cell mediated 

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Serum sickness

Accumulation of Type III mediated immune complexes in the body 

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Asthma

A combination of type 1 and type 4 hypersensitivity 

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Asthma

Wheeze 

SOB 

Chest tightness 

Cough 

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Allergic asthma

Easily recognised

usually commences in childhood 

associated with past Fhx of allergic disease

Eosinophillic inflammation

Good response to ICS

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Non-allergic asthma

Sputum may be neutrophilic 

Eosinophilic or with few inflamm cells 

Less response to ICS 

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Late onset asthma

More common in women

Tendency to be non-allergic

 Higher doses of ICS required 

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Asthma with fixed airflow limitation

Long-standing 

Airflow limitation due to airway remodelling 

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SABA

Salbutamol

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LABA

Formoterol

Salmeterol 

Vilanterol 

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Short acting anticholinergic/musc antagonist

Ipratropium 

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Long acting antiC/M antagonists

Tiotropium

Umeclidinium 

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Histamine and Leukotriens

Bronchoconstrictor mediators from Mast cells 

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Tiotropium

10% increase when combined with SABA 

Attenuates IL-13 goblet induced metaplasia 

(IL-13 most important cytokine in hypersecretion) 

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ICS

Group of drugs that:

Suppress the Th2 airway inflammation

Reducing infiltration and activating of eosinophils 

as well as other cells 

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Long acting ICS

Fluticasone Furoate 

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FF / Vilanterol

Only licensed ICS/LABA in asthma 

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