-Causes of Bilateral Ptosis :
• MG
• Dystrophia myotonica
• Tabes dorsalis
• Congenital
• Bilateral Horner's.
#Neurology
• MG
• Dystrophia myotonica
• Tabes dorsalis
• Congenital
• Bilateral Horner's.
#Neurology
•In linitis plastica:
-The mucosa is often spared malignant infiltration, making endoscopic diagnosis extremely difficult.
-Therfore,multiple endoscopic biopsies are recquired.
#Stomach
-The mucosa is often spared malignant infiltration, making endoscopic diagnosis extremely difficult.
-Therfore,multiple endoscopic biopsies are recquired.
#Stomach
-In gastric linitis plastica
Most of the patients presenting with symptoms have an advanced form of the disease.
#Stomach
Most of the patients presenting with symptoms have an advanced form of the disease.
#Stomach
•Main features of graves disaese include :
-Diffuse goiter
-Thyroid eye disease
-Pretibial myxoedema
-Thyroid acropathy.
#Thyroid
#Endocrine
-Diffuse goiter
-Thyroid eye disease
-Pretibial myxoedema
-Thyroid acropathy.
#Thyroid
#Endocrine
•Parameters indicate severe diabetic ketoacidosis:
-pH < 7
-Blood ketone > 6 mmol/L
-Bicarbonate < 5 mmol/L
-Anion gap >16 mmol/l
-Potassium < 3.5 mmol/L on admission
-Tachycardia or bradycardia
-Systolic blood pressure <90 mmHg
-Oxygen saturation <92% on air
-GCS < 12.
#Diabetes
-pH < 7
-Blood ketone > 6 mmol/L
-Bicarbonate < 5 mmol/L
-Anion gap >16 mmol/l
-Potassium < 3.5 mmol/L on admission
-Tachycardia or bradycardia
-Systolic blood pressure <90 mmHg
-Oxygen saturation <92% on air
-GCS < 12.
#Diabetes
•Indications of DC cardioversion in AF are:
1-Blood pressure less than 90 mmHg
2-Chest pain
3-Heart failure
4-Impaired consciousness.
5-HR > 200 bpm.
#Cardiology
1-Blood pressure less than 90 mmHg
2-Chest pain
3-Heart failure
4-Impaired consciousness.
5-HR > 200 bpm.
#Cardiology
-The tendency of breast cancer to metastasize to the spine is explained by the free communication of posterior intercostal veins with vertebral venous plexus.
#Breast
#Breast
-Cancer Antigen 15-3 (CA 15-3 )is the tumor marker for breast cancer .
-It is elevated in large or disseminated tumors.
-It is not useful for diagnosis but it is used to monitor response to breast cancer treatment and disease recurrence .
#Breast
-It is elevated in large or disseminated tumors.
-It is not useful for diagnosis but it is used to monitor response to breast cancer treatment and disease recurrence .
#Breast
Arm edema after breast cancer treatment
◼️Axillary lymph node dissection combined with radical radiotherapy causes destruction of the lymphatic drainage of the upper limb with consequence lymphatic edema.
◼️The condition is now uncommon because radical radiotherapy and axillary lymph node dissection are rarely combined together, but it still can occasionally occur even if either modalities are used alone.
◼️It may take months or years to develop, but when it develops it is very essential to exclude recurrence of cancer which infilerate the axilla and cause both lymphatic and venous occlusion.
◼️Axillary infilteration by tumor cells can be so painful, because of brachial plexus nerve involvement.
◼️Treatment is by arm elevation, elastic arm stockings and pneumatic compression devices, it can prove difficult to treat.
◼️The above is a patient who is suffering from left arm lymph edema following radical axillary dissection.
#Breast
◼️Axillary lymph node dissection combined with radical radiotherapy causes destruction of the lymphatic drainage of the upper limb with consequence lymphatic edema.
◼️The condition is now uncommon because radical radiotherapy and axillary lymph node dissection are rarely combined together, but it still can occasionally occur even if either modalities are used alone.
◼️It may take months or years to develop, but when it develops it is very essential to exclude recurrence of cancer which infilerate the axilla and cause both lymphatic and venous occlusion.
◼️Axillary infilteration by tumor cells can be so painful, because of brachial plexus nerve involvement.
◼️Treatment is by arm elevation, elastic arm stockings and pneumatic compression devices, it can prove difficult to treat.
◼️The above is a patient who is suffering from left arm lymph edema following radical axillary dissection.
#Breast
Skin manifestations of breast cancer
◼️Dimpling = the tumor pulls the skin into a pit by fibrosis acted upon via cooper's ligament (conical ligaments connecting skin to pectoralis
fascia).
◼️Puckering = multiple dimplings.
◼️Tethering = Tumor is connected to cooper's ligaments but did not cause a dimpling, however when the patient lifts up the arms and breast skin is stretched, a pit appear.
◼️Malignant ulcer = tumor has broken through the skin.
◼️Fungating tumor = see image above.
◼️Peau d orange = cutaneous lymphedema due to malignant lymphatic obstruction (see before).
◼️Cancer en cuirasse = the skin is infilterated by malignant cells forming a shield like coat. Word 'cuirasse' is french for armour or shield worn as a breast plate.
#Breast
◼️Dimpling = the tumor pulls the skin into a pit by fibrosis acted upon via cooper's ligament (conical ligaments connecting skin to pectoralis
fascia).
◼️Puckering = multiple dimplings.
◼️Tethering = Tumor is connected to cooper's ligaments but did not cause a dimpling, however when the patient lifts up the arms and breast skin is stretched, a pit appear.
◼️Malignant ulcer = tumor has broken through the skin.
◼️Fungating tumor = see image above.
◼️Peau d orange = cutaneous lymphedema due to malignant lymphatic obstruction (see before).
◼️Cancer en cuirasse = the skin is infilterated by malignant cells forming a shield like coat. Word 'cuirasse' is french for armour or shield worn as a breast plate.
#Breast
Ductal carcinoma in situ (DCIS)
◼️This is a pre-invasive stage of breast cancer in which malignant cells had not breached the basement membrane of mammary ducts.
◼️In the early stages, the proliferating cells grows into a papillary projections (see figure above) which is simply known as the papillary type, here it may be difficult to differentiate DCIS from simple hyperplasia seen commonly in women with fibrocystic breasts.
◼️Later on these papilla grows even more with spaces inbetween the clumps of malignant cells, this is called the Cribriform type, eventually these cells obliterate the lumen of the duct completely, and this is called the Solid type.
◼️When the cells overgrow their blood supply, necrotic areas appear which undergo microcalcifications seen on mammography, this is called the Comedo type which is considered to have a high risk of progression to invasive cancer.
◼️N.B Lobular carcinoma in situ is a marker of risk and not a direct anatomic precursor to malignancy.
#Breast
◼️This is a pre-invasive stage of breast cancer in which malignant cells had not breached the basement membrane of mammary ducts.
◼️In the early stages, the proliferating cells grows into a papillary projections (see figure above) which is simply known as the papillary type, here it may be difficult to differentiate DCIS from simple hyperplasia seen commonly in women with fibrocystic breasts.
◼️Later on these papilla grows even more with spaces inbetween the clumps of malignant cells, this is called the Cribriform type, eventually these cells obliterate the lumen of the duct completely, and this is called the Solid type.
◼️When the cells overgrow their blood supply, necrotic areas appear which undergo microcalcifications seen on mammography, this is called the Comedo type which is considered to have a high risk of progression to invasive cancer.
◼️N.B Lobular carcinoma in situ is a marker of risk and not a direct anatomic precursor to malignancy.
#Breast
Role of axillary surgery in breast cancer
◼️It is accepted that, presence of metastatic deposits in axillary lymph nodes is still the single best marker of prognosis, despite this removal of axillary lymph nodes do not improve survival because it is not a reservoir of disease but merely a reflection of the metastatic potential of the disease, this means that presence of lymph node metastasis likely means presence of distant micrometastases that cannot be detected, therefore axillary surgery is justified for staging not for improving survival, and when positive systemic chemotherapy is justified.
◼️Above fig shows the groups of axillary lymph nodes:
1) Interpectoral group (Rotter nodes).
2) Anterior Group along the free edge of pectoralis major.
3) Posterior group on subscapularis muscle.
4) Lateral group along axillary vein.
5) Central group embedded in the centre of axilla.
6) Apical Group, which is continuous with lateral group but above the pectoralis minor muscle.
#Breast
◼️It is accepted that, presence of metastatic deposits in axillary lymph nodes is still the single best marker of prognosis, despite this removal of axillary lymph nodes do not improve survival because it is not a reservoir of disease but merely a reflection of the metastatic potential of the disease, this means that presence of lymph node metastasis likely means presence of distant micrometastases that cannot be detected, therefore axillary surgery is justified for staging not for improving survival, and when positive systemic chemotherapy is justified.
◼️Above fig shows the groups of axillary lymph nodes:
1) Interpectoral group (Rotter nodes).
2) Anterior Group along the free edge of pectoralis major.
3) Posterior group on subscapularis muscle.
4) Lateral group along axillary vein.
5) Central group embedded in the centre of axilla.
6) Apical Group, which is continuous with lateral group but above the pectoralis minor muscle.
#Breast
Note
Indications of mastectomy in early breast cancer rather than wide local excision followed by radiotherapy are:
1) Large tumour in relation to the size of the breast.
2) Central tumour below or involving the nipple.
3) Multifocality/ Multicentricity.
4) Patient's preference.
5) Local recurrence.
#Breast
Indications of mastectomy in early breast cancer rather than wide local excision followed by radiotherapy are:
1) Large tumour in relation to the size of the breast.
2) Central tumour below or involving the nipple.
3) Multifocality/ Multicentricity.
4) Patient's preference.
5) Local recurrence.
#Breast
Side topic
-HER2/NEU receptor (Human epidermal growth factor 2) is a membrane bound protein that has three domains, extracellular domain which interact with an unknown ligand, transmembrane part, and intracellular domain which initiate several signaling pathways.
-HER2 receptor, when stimulated promote cellular proliferation.
-Overexpression of this receptor by some tumors, notably breast cancer, adenocarcinoma of lung and ovarian cancers leads to an aggressive growth, and associated with poor prognosis, although it can be used as a target for therapy using monoclonal antibodies against this receptor to block its effect, it will still be a bad finding.
#Breast
-HER2/NEU receptor (Human epidermal growth factor 2) is a membrane bound protein that has three domains, extracellular domain which interact with an unknown ligand, transmembrane part, and intracellular domain which initiate several signaling pathways.
-HER2 receptor, when stimulated promote cellular proliferation.
-Overexpression of this receptor by some tumors, notably breast cancer, adenocarcinoma of lung and ovarian cancers leads to an aggressive growth, and associated with poor prognosis, although it can be used as a target for therapy using monoclonal antibodies against this receptor to block its effect, it will still be a bad finding.
#Breast
This is a 37 years old female, she came to you complaining of a breast mass, upon examination the breasts looked symmetrical with no nipple retraction or discharge, a hard mass was palpated in the upper outer quadrant, you instructed the patient to lift up the arms, upon doing so, the above skin change was seen
.
what is the name of this sign? What is the mechanism? What do you want to do next?
-Answer: 👇🏽
#Breast
.
what is the name of this sign? What is the mechanism? What do you want to do next?
-Answer: 👇🏽
#Breast
Answer
◼️The above sign is called skin Tethering
◼️ It is due to a tumor pulling on the skin via cooper's ligament, not as much to cause dimpling but will do so when the skin is stretched by arm elevation.
◼️Next step is to carefully palpate the axillary lymph nodes.
◼️The above sign is called skin Tethering
◼️ It is due to a tumor pulling on the skin via cooper's ligament, not as much to cause dimpling but will do so when the skin is stretched by arm elevation.
◼️Next step is to carefully palpate the axillary lymph nodes.
Dealing with metastatic breast cancer
◼️The above is a radioisotope scan showing multiple metastasis (white arrows).
◼️Metastatic breast cancer is inoperable, the primary treatment is palliation to deal with the symptoms.
◼️Usually the first line therapy is hormonal therapy due to its less side effects, it is particularly useful for bony metastasis, the unfortunate reality is that only 30% are hormone sensitive, and even those which are responsive, they with time become resistant, the use of a different hormonal agent with such event may however produce half of the original response.
◼️The first line for Postmenopausal women is now anastrazole or some other 3rd generation aromatase inhibitor.
◼️Chemotherapy especially for rapidly growing visceral metastasis and young women may be considered.
◼️Local radiotherapy may prove useful for some cases for painful bony deposits, also internal fixation for pathological fractures is considered.
#Breast
◼️The above is a radioisotope scan showing multiple metastasis (white arrows).
◼️Metastatic breast cancer is inoperable, the primary treatment is palliation to deal with the symptoms.
◼️Usually the first line therapy is hormonal therapy due to its less side effects, it is particularly useful for bony metastasis, the unfortunate reality is that only 30% are hormone sensitive, and even those which are responsive, they with time become resistant, the use of a different hormonal agent with such event may however produce half of the original response.
◼️The first line for Postmenopausal women is now anastrazole or some other 3rd generation aromatase inhibitor.
◼️Chemotherapy especially for rapidly growing visceral metastasis and young women may be considered.
◼️Local radiotherapy may prove useful for some cases for painful bony deposits, also internal fixation for pathological fractures is considered.
#Breast
Notes to keep in mind when dealing with breast cancer
◼️Sadly, breast cancer has a very dark side to it,, even small tumors may have already sent distant micrometastases which cannot be detected by conventional means.
◼️Months or years later from the day when it was treated, these micrometastases appear again sometimes in multiple sites.
◼️Therefore, the outcome of treatment is predetermined by the presence or absence of micrometastases, to add to this dark side of breast cancer, sometimes these micrometastases remain dormant for very long time, and then suddently they decide to appear like a dead man from the grave (check above) 😕💔
◼️This is why the presence of axillary metastasis is a reflection of the evilness of the tumor and its metastatic potential, and this is why axillary dissection is mainly done to know the prognosis and NOT to improve survival, and also this is the reason why chemotherapy is indicated strongly in women with node positive disease
#Breast
◼️Sadly, breast cancer has a very dark side to it,, even small tumors may have already sent distant micrometastases which cannot be detected by conventional means.
◼️Months or years later from the day when it was treated, these micrometastases appear again sometimes in multiple sites.
◼️Therefore, the outcome of treatment is predetermined by the presence or absence of micrometastases, to add to this dark side of breast cancer, sometimes these micrometastases remain dormant for very long time, and then suddently they decide to appear like a dead man from the grave (check above) 😕💔
◼️This is why the presence of axillary metastasis is a reflection of the evilness of the tumor and its metastatic potential, and this is why axillary dissection is mainly done to know the prognosis and NOT to improve survival, and also this is the reason why chemotherapy is indicated strongly in women with node positive disease
#Breast
Genetic predisposition to breast cancer
BRCA1 = chromosome 17q predispose to breast cancer, ovarian cancer and to lesser extent prostate and colorectal cancer.
BRCA2 = chromosome 13 q, linked strongly with male breast cancer.
P53 = autosomal dominant, causes what so called Li Fraumeni syndrome which is the life of cancer at its fullest (rhabdomyosarcoma, breast cancer, leukemia, brain tumors, adrenal tumors and others)
N.B prophylactic mastectomy in these cases do not completely eliminate the risk of cancer, however it reduce it considerably, in general the risk of having BRCA genes is considered to be 30-50%.
#Breast
BRCA1 = chromosome 17q predispose to breast cancer, ovarian cancer and to lesser extent prostate and colorectal cancer.
BRCA2 = chromosome 13 q, linked strongly with male breast cancer.
P53 = autosomal dominant, causes what so called Li Fraumeni syndrome which is the life of cancer at its fullest (rhabdomyosarcoma, breast cancer, leukemia, brain tumors, adrenal tumors and others)
N.B prophylactic mastectomy in these cases do not completely eliminate the risk of cancer, however it reduce it considerably, in general the risk of having BRCA genes is considered to be 30-50%.
#Breast
Tip
Li Fraumeni = SBLA syndrome
S = sarcoma (rhabdomyosarcoma).
B= Breast cancer/Brain cancer (glioblastoma usually).
L= Leukemia/Lymphoma.
A= Adrenocortical carcinoma.
#Breast
Li Fraumeni = SBLA syndrome
S = sarcoma (rhabdomyosarcoma).
B= Breast cancer/Brain cancer (glioblastoma usually).
L= Leukemia/Lymphoma.
A= Adrenocortical carcinoma.
#Breast