Malignant Disease

EXAM Q1 To secure your place in your preferred FY1 post discuss the presentation and management of a rhabomyosarcoma of the middle ear

Case 1 A 65 yrs old man presents with painless jaundice of one weeks duration. Abdominal examination reveals an enlarged gallbladder (Courvoisier’s sign). A 65 yrs old man presents with painless jaundice of one weeks duration. Abdominal examination reveals an enlarged gallbladder (Courvoisier’s sign). Why is he jaundiced? Why is he jaundiced? How would you relieve his symptoms? How would you relieve his symptoms?

Case 2 A 45 yrs old woman presents with a lump in her left breast A 45 yrs old woman presents with a lump in her left breast What would you examine and why? What would you examine and why? How does this influence her treatment? How does this influence her treatment?

Case 3 A 70 yrs old man, a heavy smoker presents with weight loss, malaise, aches and pains in his bones and abdomen. A chest has confirmed an advanced lung cancer. A 70 yrs old man, a heavy smoker presents with weight loss, malaise, aches and pains in his bones and abdomen. A chest has confirmed an advanced lung cancer. What is causing his symptoms? What is causing his symptoms?

Think logically Aetiology – what can cause cancer? Aetiology – what can cause cancer? Chemical Chemical Smoking Smoking Asbestos Asbestos B-naphthylamine B-naphthylamine Physical Physical X-rays X-rays Ultraviolet light Ultraviolet light Viral Viral EB virus – Burkitt’s lymphoma EB virus – Burkitt’s lymphoma Genetic Genetic Famililial polyposis coli Famililial polyposis coli Miscellaneous Miscellaneous Geography Geography Diet Diet Drugs Drugs

Clinical Manifestations Effect of primary tumour Effect of primary tumour Effect of metastases Effect of metastases Systemic manifestations Systemic manifestations

Primary tumour Expansion Expansion Obstruction, lump Obstruction, lump Infiltration Infiltration Pain from nerve involvement Pain from nerve involvement Necrosis Necrosis Bleeding / infection Bleeding / infection

Metastases Lymphadopathy Lymphadopathy Lung secondaries (dyspnoea) Lung secondaries (dyspnoea) Liver secondaries (jaundice) Liver secondaries (jaundice) Bone secondaries (fractures) Bone secondaries (fractures) Brain secondaries (epilepsy/headache) Brain secondaries (epilepsy/headache) Skin secondaries (nodules) Skin secondaries (nodules)

Systemic manifestations Cachexia Cachexia Weight loss, anaemia, fever Weight loss, anaemia, fever Hormonal and metabolic Hormonal and metabolic Cushing’s (lung) Cushing’s (lung) ADH secretion (lung) ADH secretion (lung) Hypercalcaemia (lung / breast) Hypercalcaemia (lung / breast) Hypoglycaemia (liver) Hypoglycaemia (liver) Haematological Haematological Polycythaemia (kidney) Polycythaemia (kidney) Vascular Vascular Thrombophlebitis (lung/pancreas) Thrombophlebitis (lung/pancreas) Cutaneous Cutaneous acanthosis nigricans acanthosis nigricans dermatomyositis dermatomyositis