Part 4

Breast lump 

****** discharge and / or inversion 

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

Skin dimpling / deforrmity / puckering 

Axillary mass 

lymphoedema 

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 

Not considered breast cancer 

But a marker of increased risk 

(2)

Considered a cancer 

Remain in the basement membrane of the tubules of the breast 

Drug given to a patient who is oestrogen receptor positive 

Reduces risk of recurrence so can be continued after remission 

Stage 1 and 2 breast cancer = 

Stage 3 = 

A form of locally advanced breast cancer 

Most aggressive form 

Presents as swelling, tenderness and redness 

Sentinel lymph node biopsy is contraindicated 

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

Breast cancer = 80-90% 

High risk of sarcoma 

High risk of childhood leukaemia 

Adrenal cancer 

Clinical features 

Most common:

Anorexia and weight loss 

Cough, dyspnea 

Supraclavicular LNs 

Others: 

Chest pain, haemoptysis 

Hoarseness, dysphagia 

Bone pain, clubbing 

Neurological manifestations 

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 

80-85% of lung cancers 

Adenocarcinoma 

Squamous cell carcinoma 

Large cell 

Most common type of cancer in NSCLC 

Due to EGFR mutations 

K-ras 

and more 

What numbered lymph nodes are missed in endobronchial USS 

Stage I and II (some with IIIa)

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

No significant co-morbidities 

Chemotherapy in what cancer? 

Platinum + new agents (gemcitabine) 

Chemoradiotherapy in N2/N3 disease + immune therapy 

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 

Pembrolizumab

Treat with:

Pembrolizumab 

Platinum chemo 

Nivolumab 

Treat with:

Platinum chemo 

Nivolumab 

Treat with 

Tyrosine kinase inhibitors (for EGFR)

Platinum chemo 

Nivolumab 

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 

Breathless at rest, speech in words or phrases 

RR >25 

Pulse >110

Loud wheeze 

<33% predicted PERF/FEV1

PaCO2 >40mmHg

PaO2 < 60mmHg 

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 

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 

Accumulation of Type III mediated immune complexes in the body 

A combination of type 1 and type 4 hypersensitivity 

Wheeze 

SOB 

Chest tightness 

Cough 

Easily recognised

usually commences in childhood 

associated with past Fhx of allergic disease

Eosinophillic inflammation

Good response to ICS

Sputum may be neutrophilic 

Eosinophilic or with few inflamm cells 

Less response to ICS 

More common in women

Tendency to be non-allergic

 Higher doses of ICS required 

Long-standing 

Airflow limitation due to airway remodelling 

Salbutamol

Formoterol

Salmeterol 

Vilanterol 

Ipratropium 

Tiotropium

Umeclidinium 

Bronchoconstrictor mediators from Mast cells 

10% increase when combined with SABA 

Attenuates IL-13 goblet induced metaplasia 

(IL-13 most important cytokine in hypersecretion) 

Group of drugs that:

Suppress the Th2 airway inflammation

Reducing infiltration and activating of eosinophils 

as well as other cells 

Fluticasone Furoate 

Only licensed ICS/LABA in asthma