Remember

If u see migratory thrombophlebitis, look for visceral malignancies.

Selective Estrogen Receptor Modulators

Clomifene: @ hypothalamus: antagonist

Raloxifene:                              @breast :antagonist   @bone: agonist   @uterus: antagonist

Tamoxifene:                            @breast :antagonist   @bone: agonist   @uterus: agonist

Others include: femarelle, toremifene etc.


All reduce risk of breast cancer
All reduce risk of postmenopausal osteoporosis
Tamoxifene increases risk of endometrial cancer
SERMs increase risk of DVT

Clomifene used for treatment of infertility(anovulation)
Raloxifene used for treatment of Osteoporosis and breast cancer
Tamoxifene used for treatment of breast cancer

Remember

Elderly woman with new onset ascites, no Liver involvement: investigate for ovarian CA

Bone lesion differentials

Osteoid osteoma:  radioluscent (lytic) centre,usually <1cm surrounded by sclerotic lesion. Benign

Brodie's abscess: form of osteomyelitis, remains subacute for years before converting to chronic (draining) osteo. radioluscent lesion >1cm surrounded by irregular margin of sclerosis. Benign

Osteosarcoma: hard irregular spiculated lesion (moth -eaten or sun burst appearance) with periosteal elevation- Codman's triangle, . Malignant. seen more commonly in Male adolescents. Most common primary bone cancer

Ewing's sarcoma: lytic lesion with periosteal reaction- onion skinning. Malignant. Highly metastatic.Typically seen  in Male adolescsent

Low back pain; indications for imaging

Do imaging (initial: X ray, most accurate :MRI) if  there's:

point tenderness + compression symptoms


IV drug use (risk of epidural abscess) + compression symptoms


History of cancer with suspected metastases  + compression symptoms


Sciatica (disc herniation) + compression symptoms


Cauda Equina syndrome


Ankylosing spondylitis: (fused vertebrae)
young man with stiffness & low back pain worsened by rest! + Archilles tendon pain, AV block, Aortic insufficiency, uveitis, arthritis in other jts
(do Xray sacroiliac jt as initial test)




Cauda Equina syndrome is xterised by:

• Saddle anaesthesia
• Loss of sphincteric tone
• Incontinence
• leg weakness
• erectile dysfunction

Compression symptoms include:

• focal neurological deficit
• sensory loss
• hyperreflexia

(if suspected, give steroids immediately before investigation)

Cervical cancer screening

Every woman, 21-65 yrs : Pap smear for cytology every 3yrs

For those above 30, alternative is Pap smear for cytology + HPV testing every 5yrs


If cytology yields abnormal results do further tests

Atypical squamous cells of unknown significance, ASC-US:
The "significance" is not clear so check for the HPV virus
If HPV +, then do colposcopy
If HPV -, then patient goes home and returns for repeat pap smear in 12 months (instead of the usual 3 yrs)


Atypical squamous cells, cannot exclude HSIL, ASC-H:
Still not clear and even more suspicious, HSIL is a possibility so go straight and do colposcopy


Low grade squamous intraepithelial lesion, LSIL:
For premenopausal women including pregnant women, do colposcopy

For postmenopausal women, 3 options:

• Do colposcopy
• Do HPV and then colposcopy if +
• Wait and repeat in 6months and 12months

High grade squamous intraepithelial lesion, HSIL:
Do colposcopy


20% of CA cervix may arise from glandular cells but the majority, 80%, are from squamous cells

Colposcopy is done for visual inspection + targeted biopsy + endocervical curretage (EC is contraindicated in pregnancy).

Findings:

If colposcopy done following abnormal cytology does not show any CIN, repeat cytology in 12 months (or 6 months if HPV+)

CIN 1: usually regresses spontaneously
CIN 2 & 3: Cautery, LEEP, Cone biopsy

Oral contraceptives and associated risks

OCPs increase risk of

cervical cancer 
breast cancer,
DVT
hypertension.


OCPs reduce risk of

ovarian cancer
endometrial cancer

Pancreatic cancer

Elderly

Painless jaundice (cancer head of pancreas, obstructing bile flow)

Upper abdo  pain, radiating to the back (cancer originating from the body or tail of pancreas)

weight loss

Abdo mass

steatorrhea

+/- pruritus



risk factors: Family history, Elderly, smoking, obesity, DM

Superior vena cava syndrome

Suspect in patient with history and findings suggestive of bronchogenic carcinoma, with

shortness of breath
face or arm swelling
headache
upper chest vein distension
neck vein distension


Due to compression of SVC by tumour

Renal cell CA

Adult with gross painless hematuria, think of malignancy: bladder, renal, ureters
Do Contrast Abdo CT or IVU
If nothing is seen, do cystoscopy.

Note: Bladder  mass more common than renal cell CA

Renal cell CA:
hematuria, flank pain , abdo mass in 10%. Presence of lft sided varicocoele which doesn't empty when recumbent, is highly suggestive of RCC.