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Yep. Okay. Um So we'll get going, um, 603. 1st of all, I apologize for not doing a session before your muzzle ear's and risk ease. I hope they went well. Um The muzzles are notoriously very tricky, so don't beat yourself up if you came across a condition that was hard. Um I think you all have done well. Um So that today I'm going to cover cancer and immunology. Um with more, it's probably more of a quiz based um lecture today because there's not as much Maslow and risky content um to teach you. Um And I think quiz questions are probably the best way to go about it. Um So, um and I was looking through your content for fourth year with cancer immunology and genetics and it is at quite, it's at a fairly high level what they teach you. So, um I won't be teaching any of the material better than what they taught you in the seminars. But I think these coy's questions, if you sort of have rough answers to these, then you should be in good stead for the S P A. So let's get started. Um Right. So some of the court conditions we had when I took the exams as far as immunology, cancer and a bit of genetics. Um So the high yield conditions um usually relate to allergy. They usually always ask an anaphylaxis question. Um talk about hypersensitivity and then in cancer, they love breast cancer, um colorectal cancer as well. General things about cancer management and palliative care and then prostate cancer as well. Um On the genetic side, they didn't ask too much. They ask a little bit about maybe a question about fish and carry typing and a question about maybe Turner syndrome or something like that, but I haven't really covered it in this lecture. Um And then on the immunology side, they also asked some like usually a question on skid or something, something to that effect. But um these are the more high yield ones that will go through today. So starting off. So we have a breast lump. Um a 68 year old post menopausal woman presents, you're a doctor with a three month history of a painless firm lump in the upper outer quadrant of her left breast during a clinical examination. Her doctor notes that the lump is 20 millimeters at its widest. So we have 68 year old personal oppose als three month history. Um So if you guys want to um send in your answers to this question, everyone's exhausted from revision today. Um So I'll give the answer to this one. Um So the most likely diagnosis is malignancy. Um So, breast cancer, um okay, we've got any very good. Uh And the reason why is so for fat necrosis, you probably have a history of trauma fiber adenoma known as like a breast mouse. Um usually resolves in menopause and tends to be mobile. Whereas uh in this patient, uh we actually didn't say whether it was tethered or not. So that's kind of unfair. Um fibrocystic change again, usually resolves that menopause typically symmetrical and then patches disease of the breast that usually overlying skin changes um uh indicating um breast cancer behind the nipple. Okay. So the patient's referred to the One stop breast clinic um for further investigation where she undergoes clinical evaluation, mammogram, imaging and fine needle biopsy. Um and the results of the biopsy reveal a stage to be breast cancer. So, moving on to question to which of the following is the most likely initial management option for this patient. Um And if people send in their guess is it will just engage your brain a bit more. Um And I'll just give you guys a bit of time to answer the question. Okay. We're getting some ease. Very good. Okay. Um e again, lovely. Okay. So yeah, surgical reception. Um So this is the high yield point number one for SBA exams. They may ask you, you know, what is the, you know, most likely initial management for breast cancer? So, um surgery with auxiliary lymph node staging is usually the initial treatment for early stage breast cancer. So, this is a stage DB. So it's classes and um early stage breast cancer. Um So chemotherapy can be given in the neoadjuvant setting, which means preoperatively for advanced breast cancer. Um, an endocrine therapy can give it be given as an adjuvant. So, um, uh post surgery, that's what adjuvant means. And then we've got immunotherapy for advanced breast cancers and then radiotherapy um can go in combination with surgical reception. Um If it's a lumpectomy, it's usually given um alongside a lumpectomy if the patient doesn't elect for mastectomy. Okay. So, following the biopsy of the breast tissue, immunohistochemical trees performed on the tumor and this reveals an estrogen positive progesterone positive, her two positive tumor. So, in the cases of triple negative breast, you know, let's move on actually before give anything away. Right. So, question number three. So we've got estrogen positive progesterone positive in her two positive. What does her two positivity indicate? Is it a it might respond to her to antibody or is it be it's unlikely to respond to her to antibody? Okay. Very good. So it might be a bit of a leading question. Um but like a general overlying principal, they may ask you because they think it relates to immunology. So um if it's her two positive on immunohistochemical tree, they run antibody stains. So then the the cells will test positive for her too. Um And this is kind of a uh simplified schematic about how trastuzumab works. Um So it's like a monoclonal antibody actually binds to the intracellular portion of the her two and other her um proteins. But it's just important to be aware that this antibody anti gin sort of effect. Okay. So we're moving on additional management. The patient is counseled on the management options available and she elects for a lumpectomy plus adjuvant radiotherapy and endocrine treatment over the three week course of radiotherapy. She notices some side effects. So, question for which of the following is the most common side effect of radiotherapy. And I'll give you guys some time to answer. Okay. We've got a lot of d so this is where contentions comes in, in SBS as always. Um So the most common side effect of radiotherapy is actually fatigue. Um So this is certainly a question they could ask on the exam and they'll probably admit either fatigue or skin changes as, um, they're both very common side effects. Um Howard fatigue is something that most patient's notice earlier on in the radiotherapy course. And skin changes tend to happen, it can happen immediately but the um, fibrotic changes or um longer term skin changes tend turn later on, um, post radiotherapy. Um So you wouldn't be wrong per se to put the, but just um, I would keep those two in your mind to pick out if they give you those options but fatigue is definitely number one. Um So have that in your mind. Okay. So question number five. So the patient also has um endocrine therapy um alongside her breast cancer management of surgery. Um So which of the following options is the optimum therapy or it's the recommended endocrine therapy sash treatment length for her cancer. Um Bearing in mind she's sort of in her late sixties, she's post menopausal. Okay. Very good. So I see past medicines coming in handy. So we're going for anastrozole, um which is the correct answer. Um So improves disease free survival from 18% to 21% compared to tamoxifen. Um And it stimulates every's to produce estrogen and premenopausal women. So that's sort of why Tamoxifen's preferred um and premium premenopausal women. And also Tamoxifen acts as an agonist and post menopausal women. Um There is a changing area where they're trying to use anastrozole with other G N R H uh medications as um they've shown that anastrozole may be more effective in younger women as well. Um But I wouldn't worry about that. Um And just, you know, remember your hard and fast rules of anastrozole um for five years in post menopausal women and then Tamoxifen um will be five years um in premenopausal. Um And if they say switch in the meantime, uh and have the menopause during that five years, then you would switch to anastrozole. Um But yeah, I just remember your regular rules for that because it is a very common um exam question. Okie doke. So we're 10 years down the line. Um The patient recovered well from their surgery and radiotherapy and they completed their five year treatment of anastrozole. Um and they received yearly mammograms during um this period, 10 years after she initially noticed her breast lump, she notices a swelling in her axilla and she also complains of headaches occurring daily for the past six weeks. On examination. Her doctor knows that she has three enlarged auxiliary lymph nodes on the left side. So, question number six, which of the following is the most appropriate initial investigation of this patient's symptoms. So we have a bone scan, chest X ray, a ct, chest, abdomen, pelvis or a pet scan, um and moving back to the patient. So they have a swelling in their axilla. They have headaches occurring daily. Um and they also have lymph nodes and large lymph nodes on the left side. Okay. So we have some DS any other answers okay there and scan. Okay. Right. So it could be an area of contentions where I'm not up to date with the literature. Okay. We've got to see very good, very good. Anyone going for chest X ray now, right. Um Okey doke. So um this is also a common question as well. So it is difficult. So with the eggs, Ilary lymph nodes like a pet scan yet, like especially lymphoma you know, that's, that's a great scan to initiate, but because the questions asking what's the most appropriate initial investigation. Um So for staging, you would get a CT chest, abdomen pelvis. Um in an exam though they may have the option of a bone scan, which makes it a very difficult conundrum if you're faced with a case um where a patient may have rib pain or bone pain as they're presenting symptom. Um So in that case, if it is presenting as a bony lesion or rib pain or bone pain, the bone scan maybe uh requested and done first. Um however, is kind of annoying that they ask that. But I would say if in doubt goes ct chest, abdomen, pelvis, but if there is bony involvement that they will put bone scan in, in the gardens, it does say a bone scan is one of the initial investigations you can request for a suspected malignant breast cancer. Um So, and a pet scan is something you may request. Um Right. So I'll answer question seven. Um We are flying through the questions I've created. Um So the patient undergoes the ct cat bone scan. What was the relevance of the headaches? Were they suggesting brain mets? Hmm. Um So they undergo an MRI head as well which reveals metastasis to the left second rib spine and brain. So which of the following is the most appropriate initial therapy for brain metastases? Okay. Very good. So we're getting some B's anyway, anyone else? Okay. We're sticking with be okay. Very good. So, um um in your sessions, you have had cases um with people with brain metastasis or primary brain cancer. Um and best supportive care um for people with brain Mets is dexamethasone plus or minus anti epileptic therapy. Um So, the theory of dexamethasone is it reduces intracranial um swelling um resulting in less symptoms. So she's got these headaches. Um And then, so anti epileptic therapy, um someone's first presentation of a metastasis, maybe a seizure. Um So, if that were the case, you know, they've had the suspicious um eggs, Ilary nodes falling breast, um breast cancer and they've had a scan. So maybe they'll start antiepileptics before dexamethasone. Um radiotherapy um is definitely an option that will um usually be used in people with metastatic breast cancer of the brain. But um it's not the initial therapy. Um So you can't go wrong with dexamethasone. Um Okay. So, question number eight. So we're the patient is started on Pertuzumab plus Trust to use a mob which you guys don't need to know um as well as palliative radiotherapy of her bone. Fantastic sis. So, um which of the following is the main goal of palliative therapy. Ok. Brilliant. So we're going a lot for be. Um And I know these questions may seem simple. Um But it's important to have the basics of what treatments you're doing, right. So, um potentially may think it's to reduce tumor size. Um as this may help symptoms and it may be um an effect of the palliative care, uh palliative therapy, but um overall is to improve quality of life. Uh So that's something we were asked about in our exams. So, something you guys will obviously get right as well. Unfortunately, the patient does not respond to chemotherapy and develops acute shortness of breath with signs of heart failure has by basal crackles on auscultation and as a dermatitis from her ankles to the mid calves, the oncology and palliative team determined she should be placed on the end of life treatment. Half a which of the following is the most appropriate therapy to treat her breathlessness. Okay, getting a lot of d okay. Um So some of you guys may have attended my, my last session um about morphine um for breathlessness where you may have just been taught this um in medical school. Um But it's part of the end of life management um bundle. Um and it's used for breathlessness. Um So even though she's presenting with symptoms of acute heart failure, um morphine is something you would do to keep them comfortable and it really doesn't prove their breathlessness. And it's a question they like to ask. Uh and they asked it both in the, in the January and the summer exams. So it's definitely one to be aware of. Okie doke. So braca testing. So, following the patient's death their daughter begins researching risk factors for breast cancer. Uh and comes across an article discussing BRACA one and bratitude pathogenic variants. She attends her G P and requests Bracha testing. She has no personal history of breast cancer or other family, history of breast cancer and no history of ovarian cancer in the family either. So which of the following should be offered? Um Should they offer bracket testing or should there be no bracket testing in this case? So we've got to be anyone else. Okay. We've got all right, be, yeah, so this is on the spectrum of the more, slightly more difficult questions they might ask. Um, so in this case, um, you would not offer bracket testing. Um, and you guys do go through a session based on like percentage risk scores and referral to genetic um, screening. Um, so people that would be referred at primary care to specialist genetic clinic would need to first degree relatives younger than 50 years of age. Um So the daughter only had her mother, um, have the history of breast cancer and that was that in a sort of an advanced age. Um, so you wouldn't offer bracket testing in this case and there's no family history of ovarian um, cancer. So they may also ask this question, um, saying, you know, would you offer bracket testing but also have enhanced screening or would you do know bracket testing but offer enhanced screening or, you know, outright no bracket testing. Um, so a few of you are writing a, so, um, understanding the nice guy in series from 2004 and doctor either Richard Martin or Paul Brennan would have done genetic sessions on you with you. But the question we had in our exams was identical to this and, and you know, there was no bracket testing required for this, this patient. Okie Doke. So, moving on. So a different case now. So an 85 year old lady complains of rectal bleeding. She develops blood mixed in with the stool and a change from her normal bowel habit as she is going more frequently than normal. She has also experienced some crampy, left sided abdominal pain and weight loss. She has a background of obesity, osteoarthritis and hypertension. She lives in a bungalow and struggles with the stairs. Examination of that should say her abdomen and digital rectal examination are normal. She underwent a sigmoidoscopy which was negative. Mm. Yeah. So which of the following is the most appropriate um, next investigation for this patient. So, should they have no further investigations? Should they have a repeat sigmoidoscopy? Should they obtain a CT colonoscopy or get a colonoscopy? Got some DS. Any other answers? Okay. We're sticking with these Okie Doke. So this is a question I'll ask as well. Um So the patient, so this is obviously patient dependent and we shouldn't um the prejudice or discriminate against older people as you know, they're still living healthy lives. Um, but in this case, she's an 85 year old lady. She lives in a bungalow struggles with her stairs. She's got obesity, osteoarthritis and hypertension. So she has a lot of, um, co morbidities. Um And so in someone like this or someone who's, you know, for like, you know, um, low B M I older gentleman, someone who's really frail. Um, the investigation of choice would usually be the CT colonoscopy because it's, it's less invasive. It's similarly sensitive to colonoscopy was slightly less reduced specificity. Um And it's preferred in patient's on suitable for colonoscopy are unwilling to undergo colonoscopy. Um So it's probably the most appropriate investigation giving her background of health conditions. Colonoscopy is the gold standard. Um And obviously you can obtain biopsies of the cancer. Um But it really just depends. So if you come across a question, whether it's a really frail patient and they give you the option of going for CT colonography, they are hinting at, you know, this patient is very frail and a colonoscopy, maybe um a risk to them because bowel prep, um you know, there's can be excessive dehydration with that and there's a risk of preparation and not tolerating it. So, ct colonography, but I understand people going for colonoscopy um here. So some further quick hits on malignancy. Um So there's a ton, absolute ton I didn't cover on cancer because um as a research topic and has something to know about is just huge. But here's some other things that are important. Um So, estrogen is protective for ovarian cancer. Um That's the question that may come up on the exam. Melanoma. The Breslow thickness is the number one most important prognostic indicator. Um Surprisingly, they do like to ask a bit about skin conditions. Um in your ace conditions, there may be some things on eczema or psoriasis. Um So there is a little bit of skin management sprinkled in there. But that's for Melanoma. Um knowing the general cancer markers is quite useful. So AFP for going Adal cancer um and liver cancer C A 153 for breast cancer, see a 19.9 for pancreatic cancer, obviously see a 125 for ovarian C E A for colorectal cancer. But it's can't be used as a screening tool. It's just a moderate, moderate uh monitor disease, uh severity and remission and people with corn cancer and then PS PSA for prostate cancer and then there's fit test screening which is changing a lot in the United Kingdom. Um And it's also can be used in people who initially have symptoms of P R bleeding. But in the screening program, it's primarily used to identify a symptomatic cases. So that's um ties in with our public health knowledge of screening. Um So that's quite important to know as well. Um So there's not too much longer of the session. Um So just another case of food at school. A seven year old girl presents in severe respiratory distress to accident and emergency shortly after ingesting a biscuit at school. She been complaining about flushing peratis and diaphoresis iss followed by throat tightness, wheezing and dyspnea. So which of the following is the most appropriate initial management for this patient. So we have I am adrenaline, I'm adrenaline plus hydrocortisone, I am adrenaline plus hydrocortisone and chlorphenamine or I'm adrenaline plus chloramphenicol mean. So we're going for a any other taker's. No. Okay. Yes. So, um the guidance changed. Um I think last year, um and the Royal College of Physicians recommended just I am adrenaline as an initial um treatment for anaphylaxis because they found that um in certain cases giving hydrocortisone or giving chloramphenicol mean was distracting from giving the adrenaline, which is the most important medication to give. Um interestingly in exams. Uh they may give you a scenario where someone's ingested uh some shrimp and you know, they're getting angio edema of the mouth, but they're not getting anaphylaxis symptoms of uh respiratory distress or stridor or anything like that. Um And it may be quite difficult to decide what to choose. Um There is guidance that chlor amphetamine can be used to treat skin symptoms once the ABC features resolved, especially if they have urticaria or angioedema. Um So it's just something to be aware of. Um I would probably, if in doubt, just stick with I am adrenaline because it is a bit of a nasty question if they would ask it due to the guidance changing. Um but I would just be aware of that. Okay. So, following her anaphylactic reaction, the patient is referred to an app. Oh, dear, I've given you an answer anyway, it's fine. Um So which of the following cells and antibodies mediates the skin reaction? So this is also quite a straightforward um question um that you need to know. So mast cells is pathophysiology that we've been told about asthma from the early years of medical school. And it's I G E um mediated reaction, um releasing leukotriene and histamine uh promoting days of dilation. Um too, if they have a question, you know, pay a child, there might be, you know, exposure to cat dander when they're at their grandma's house and they just may ask you what immune cells are involved in the skin patch testing or allergy. And this is, this is the answer my cells I G P. Okie doke. So I apologize. That's quite a brief session. Um and it doesn't really teach you anything new. But I think um going over those questions will put you in quite a good position because they are high yield and there's something that could potentially come up. So, um I, I hope that was useful. I apologize for not making a session earlier in your exam preparation. There should be another S P A quiz that's longer than this. That will probably be, um, either happening on the weekend or Monday before your exams. Hope revisions going well. Fourth year is definitely a tough year, but you guys can do this and you're through sort of the hardest bit. Um, I think you'll, uh, exceed expectations and, um, if you have any questions or need to email me, um, either myself or Charlie will be emailing out the slides, um, if you fill in the feedback. Um So if other people have questions or anything like that, just let me know or have a problem with the content. I'm happy to hear about it. So, good luck. No, Crock Leno. Also, I'm will, by the way, not Charles Cloak, if anyone has been paying attention, I'm doing the sessions. Mhm.