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Good, good evening everyone. Thank you for joining. Um Just gonna wait one or two more minutes to give more time for people to join and then we'll make a start. Ok. So let's start cos we've got quite a bit um to go. Ok, so welcome to um OK, before I start, just going on, um Can you guys hear me? OK. Can anyone go in the chart if you can hear and see the slides? OK. Amazing. Amazing. OK. So welcome to our um uh oncology Imaging teaching series. Um uh part of as part of our um national collaborative um teaching with um uh Ir Juniors and some of the medical schools. So today in this session, we're going to go over some high yield um cancer topics um especially when they link into like imaging. So whether it's a uh plain radiographs or um CT S or pet CT S or ultrasounds. So I've got quite a bit of um um good content. Um And, and I'm gonna be asking for your engagement as well cos to keep the session more enjoyable. So please feel free to join the chat. Um OK, so first case we've got John Smith, a 50 year old male who presents to Ed um with complaints of progressive shortness of breath over the past six months, reports that the shortness of breath has worsened with exertion and is associated with a persistent productive cough with streaks of blood. Additionally, John mentions unintentional weight loss of approximately 15 lbs over the same period. He denies any chest pain but claims he has had to change his bed sheets regularly due to sweating at night. His past medical history are hypertension co PD diabetes and hyperlipidemia. His mum died of breast breast cancer at the age of 73. He's a smoker. He smoked, he has a 30 pack year smoking history. And on examination, we find that he has diminished breath. Sounds expiratory, wheeze and a stony dull percussion on his right side. So going over the history, let's just highlight some of the important, important um parts. So he's male. He's got this progressive shortness of breath over quite a short period of time. Six months, he's got a persistent uh cough and um hemoptysis with blood. He has got weight loss and he's got night sweats. He has a chronic respiratory condition. He's got diabetes that can cause immunosuppression. He's a smoker. So essentially he has a lot of the risk factors for cancer, lung cancer and on examination, he's got wheezing, diminished breath sounds and a stony, dull percussion. So, stony dull. So what kind of finding you expecting to see on his X ray. Yeah. So, um, so pleural effusion, right? So what differentials are we, are we thinking? So it can be lung cancer? He has the risk factors can be pleural effusion, cos he's got a stone, do it can be pneumonia. We don't know it can be intertissue lung disease. It can be multiple of these factors at the same time as well. All right. So, but we have these in mind now, we need to do some more investigations, right? So we check the blood. So F PC check for any, there's if there is any anemia, if there is any thrombocytosis. So, in lung cancer, they can get thrombocytosis. C RP check for infections using these for hypernatremia. So that's important because in lung cancers, we can get paraneoplastic syndromes, right? And we'll get to those and in uh one of them you get a DH secretion and that can cause hypernatremia. So we need to check for that LFT Smets bone profile. So is the ap raised that can be a sign of bone metastasis, what's the calcium level? And then we need to do an imaging. So if we need to do a chest X ray. So on the chest X ray, we see this, can anyone put in the chat what they are seeing on to the obvious finding here? Yeah, brilliant. So there's pleural effusion on the right side and you can see there's the meniscus sign and there's also a bit of fuzziness. I don't know if you can see on the right side. Um So there is pleural effusion going on, but there can, there is also some element of um something else going on. You know, it can be atelectasis. Uh It can be consolidation, we don't know. So we need to do more investigation and just to note the mediastinum and the heart are not displaced. So we can see the Carino is quite central. Um, you can follow the trachea as well as the mediastinum. They're not um, deviated. So just to make a note of note of that. Ok. So what in the next step, what other investigations do we need to know? Can you guys, um, what do you guys think? So when I come to the um med all page to check the chat, the presentation changes, but don't mind that. Yeah. So we need to do an aspiration of the pleural effusion to see what it is. Brilliant. Anything else? Yeah. So, cytology. So I, I was kind of hoping it would come as a stepwise thing. But, ok, so we need to do some more imaging. So we need to do act chest, abdomen and pelvis. Um for cos that will help us find out what's the underlying cause, what's causing the pleural effusion and also will help us if it is malignancy, uh which we're thinking at the moment, it will help with the staging of it. And we can do a pet CT on uh after that to check for any um metastasis. Right. Then if it is cancer, if there is malignancy or if you suspect it's malignancy, we need to biopsy the lesion. Now, there are different ways of doing a biopsy. You can do an endobronchial ultrasound, guided biopsy. Now, that's good for central cancers when the uh malignancies around the, the bronchi and the bronchioles, um, we can do a percutaneous biopsy or act guided biopsy. And now these are best uh best for more peripheral tumors, er, that are not accessible uh by going down the, the bronchi. So we need to do biopsy and histology. Then as correctly mentioned, we need to aspirate the fluid and find out uh find out some more information about it, right? Uh So we need to send it for ph analysis, protein lactate dehydrogenase cytology and microbiology, right? And uh based on the protein level in the er per fluid, we can come to a essentially a better understanding of the nature of the this uh fluid. So whether it's a transit or whether it's an exit, so if it's less than 30 g per liter protein, that indicates that it's a transit. If it's more than 30 it's likely to be an accident. But when it's somewhere in between like in between 25 and 35 that's a bit ambiguous. So that's when the light criteria comes, comes into effect. So that's just a bit of, um, it's just a bit of revision, not really radiology related, but does anyone remember what like criteria um is and what it entails? Yeah, it's ok. If not. So, essentially, um if the protein, uh plural flu of er, pleural er, fluid protein is more than half the amount of the serum protein or if the uh pleural fluid LDH is more than two thirds of the serum LDH then uh and protein between 25 and 35 g per liter. Then uh our pleural fluid is likely to be um exit in nature. And uh alas we need to do a pulmonary function test. Now, that's important because um one of the management options for cancer depending on um well, what it is, what grade it is and what stage it is, it can be surgery and lung resection. So, um and one of the contraindications for uh lung resection is if the force expiratory volume in one second is less than 1.5. So that's why we need to do a pulmonary function test beforehand as well. Um OK. So here we uh have act and hopefully this will play. OK. Amazing. Um So we're gonna go through this CT scan. So, can anyone tell me what they're seeing here? So, what can you see here? Yeah. So we can see a right sided pleural effusion, right? So, uh in this patient, um the pleural uh fluid has been partially drained. Um So they don't fully drain the um uh pleural effusion because to mitigate the risk of reexpansion, edema cos if you drain all of it, then it'll create a big negative er pressure and it will cause more edema happening. So they partially drain it. So there is still some fluid there. And um and because the patient's lying down, that's why you get the pool fluid um on the posterior aspect of the patient. All right. So, and then we go and we see that there is this threes. Yeah. Do you see the tumor? So it's encompassing the um it's on the vasculature as well as the airway. Did you see this is the, um this is the um the right uh bronch cases narrowed because of the effect of the, of the malignancy. So, yeah. And um right. So, so we do the histology and it comes back as small cell, lung cancer. Ok. There are different types of small cell lung cancer. Um Sorry, there are different types of lung cancer. You have small cell and then you have non small cell and non small cell is more common. Um overall, and it's got different types like adenocarcinoma, squamous cell carcinoma, and large cell carcinoma. But small cell lung cancer is um quite aggressive, it metastasize early and is almost exclusively seen in um in spoke and also in terms of its origin, uh small cell lung cancer is a cancer of a pot. Um uh neuroendocrine cells. So, a pod stands for a mean something I can't remember off the top of my head. But yeah, it's a new endocrine cell. Um, and usually we get small cell lung cancers centrally. Same with squamous cell, er, squamous cell lung cancers. You also get them more centrally. While in contrast, adenocarcinomas, you usually see them peripherally. Uh, but again, this is just like, it's not always the case. Um, yeah, almost exclusively seen as many smokers. Yeah, usually has a poor prognosis because it spreads quite early and it is associated with paraneoplastic syndromes. So, paraneoplastic syndromes are essentially syndromes caused by non metastatic effect of the malignancy. Um So small cell lung cancer is associated with these paraneoplastic syndromes. So, atopic ACTH production that can cause um cushingoid symptoms, uh ectopic A DH that can cause um syndrome of inappropriate A DH. So that's why we mentioned, as we mentioned. Uh it I it's important to check for hypernatremia and as well as Lambert Eaton syndrome, which targets voltage gated calcium channels and it causes muscle weakness, proximal muscle weakness, especially um with bulb of muscle. So, swallowing, uh it can cause slurred speech, it can cause um difficulty climbing up the stairs, er, or standing from a seated position. Now, just as a cos I think this is a good time for revision. Does anyone know how to differentiate Lambert Eaton syndrome with Myasthenia? Gravis cos both can present in a similar way, right? So in myasthenia gravis, one of its characteristics is its fatiguability. So, after repeated movement, the muscle becomes er, more fatigued, er, and um weakness becomes more exacerbated. But in Lambert Eaton Syndrome, it actually improves with activities. So after exercise, it actually the symptoms improve. So, yeah, that's just the little point. Right. So small lung cancers, as we said, is quite aggressive and it spreads early so it can spread to other parts of the lung. It can spread to the um hilar lymph nodes and um supraclavicular lymph nodes. These are very at more risk and outside the lungs, it can metastasize to um liver adrenals, bone and brain. So lab and um and here you can see the um some histological um appearances of um different types of cancer. So small cell lung cancer is very like hyperchromatic adenocarcinoma. So, it's a cancer of glandular tissue origin. So you get these mucinous cells so you get these white bits, um squamous cell carcinomas, they can have pockets of keratin um and such, right? So this um image is er of another case actually. Um So in this one, the cancer is on the left side but it is still small cell lung cancer. And um and it's metastatic. Now, I'm gonna play it and I want you guys to have a guess of um where the cancer has metastasized to. So now she's going back. But, yeah. Does anyone want to have a guess? Yeah, the liver. Yeah, that's a good, good gas. Anything else? Any, any other suggestions please? It, yeah. So, uh let's just go through it. So here we can see uh the top, that's the primary lesion, the primary tumor lighting up. Um So in pet CT, essentially, uh they give patients um a radioactive glucose F DG or fluorodeoxyglucose. And um so tissues are have high activity but light up. So here the primary tumors are very like of high activity cos they're replicating. So they tend to light up as well. So you can see the primary team is lighting up, the heart is lighting up, not because there is metastasis there because just the heart is a very active tissue. And if you played a bit further, so I can see the kidneys are lighting up cos they are uh filtering the glucose out as well as the same reason why the bladder is lighting up. But here you can see there's something above the right um kidney dice very active and liver is a very good shout. But as you can see, there isn't anything, any point, any, any other um point of um higher activity in, in other parts of the liver, you know, cos liver is like here more interiorly, more anteriorly. Um And when you look at it because this is a corridor view and when you look at it at the axial view and the sagittal view, it becomes clear that it's actually a right. Adrenal um, metastasis. So it's a big, right? Adrenal metastasis. Yeah. Ok. So um following up on John, after six months, John presents to Ed with worsening shortness of breath. Addressed he's got head fullness, he's got headache. He's got a puffy red face and when you're examining him, you see he's got distended veins on his um, neck and chest. Now, what, what do you think is happening? Yeah. Brilliant. So the first thing that we need to be on the lookout for is S VC O, right? So S VC O stands for superior vena cava obstruction. Now, that's one of the presentations that you can, when you see, you can diagnose pretty confidently a patient with cancer and uh and you need to send them to the hospital immediately. Now, it can be caused by lung cancers or small cell and non small cell as well as lymphomas, which is usually non hodgkin lymphomas. And uh you can see their presentation on the um on the right side. If you go through the symptoms, they'll have shortness of breath, they'll have um a headache which is worse when bending forwards because the gravity will be pulling. Um because the problem is the venous drainage uh and when they bend forward, gravity will pool the blood in their um in the head and the upper lips, uh facial porra. So like a redness of the face, the extended neck, uh veins on the neck and chest wall head fullness and uh facial and upper limb edema. And there is a the Pemberton test. So it is when you ask the patient to raise their uh their arm for 1 to 2 minutes and then you'll see their face becoming more red, they'll become more breathless and more their face becoming more um edematous as you can see on the um the top, right, uh two pictures. Um and for investigation, we need to first do a chest X ray because we need to rule out if there is any other pathology happening, if there is anything else causing it. Secondly, you need to do act and act is um diagnostic and it needs to be with contrast for management. So again, we go through like an a two week. So if, if there is um compromised airway, compromised breathing, um they may need intubation and they may need um steroids. So, um hy do steroids will reduce the edema, especially if the um the larynx has become edematous and it's obstructing the, the airway, the steroids will help for management. It's important to um elevate the head to help with the venous drainage, you know, um use the gravity to um uh keep the blood going, give you oxygen uh for shortness of breath as well as opioids can help with uh that sensation of breathlessness and um surgical management will be endovenous stenting. So that would be like um the definitive one. And we also need to treat the underlying cancer. So, if it's small cell lung cancer or lymphomas chemotherapy is usually better. But if it's a non small cell lung cancer, um radiotherapy may be better. But again, that depends on the MDT assessment. So right here, we'll be looking at some complications of lung cancer. Um So the, the one on the left, that's so it's just a widened mediastinum. So we have got uh higher involvement. Um And the mediastinum has become widened, the one in the middle, we're gonna look into it. It's um S PCO the one on the right. Can anyone tell me what they see in the um right radiograph? So if you look at the, the um right upper lobe, we'll see that there is an ification going on there, right? And um and then if you look at the diaphragm, we'll see that it's raised on the right side. So, essentially, that's um so it's a right envelope collapse atelectasis. And um so again, together with the clinical picture, it will make more sense, but um it's the at the atelectasis secondary to cancer. So, the complications of lung cancer, especially on the radiograph, the things that can be seen are widened, mediastinum, right upper lobe collapse atelectasis, S VC O and um uh elevated heavy diaphragm. Now, can anyone think of any another reason apart from atelectasis that could cause a, an elevated he diaphragm in uh lung cancer? Ok. Yes. Yeah, absolutely. Um Jack is correct. So, phrenic nerve um in a VT diaphragm. Now, if the cancer um grows into the phrenic nerve that can cause um for palsy and elevated he diaphragm. Now, OK. So the video in the middle is uh showing um superior vena cava obstruction, right? So we do um it's important to do a CT with contrast. And um so when you do a con with contrast, you can do it at different phases. And that means when you do the imaging, after giving the contrast, so if you give the contrast and then do the imaging straight away, it will show you it will be in the arterial face. So the contrast will be mainly in the arteries. But if you weigh a little and then do act, then the contrast will have time to go into the vein. So the veins will be more clearer to see. So this is act um with contrast in the venous phase and um as you can see, so you pass the tumor, so there is a bilateral uh pleural effusion going on as well, right. So if you look at here, so that white, so we can see the liver, right, that's the liver and that's the inferior vena cava, which is very bright cos it's quite patent. But if you go higher. So if you, if you just follow that inferior vena cava, it goes up, all right. So any joints with the right art uh right atrium Right. And then we just follow it. Yes. Yeah, I don't know if you can see, but now D3 Vena Cava is narrower and also it's barely bright, there's barely contrast in it. So it shows that the, the compression um essentially it shows the effect of the compression. Um Yeah, I hope that makes sense. But yeah, that was an interesting image just wanted to share it. Um Yeah. Right. So now we go on to another case. So here we have a 62 year old woman who arrives at the hospital with a sudden onset of back pain. She's got weakness in her legs, difficulty walking and reports numbness in her lower body and has got a recent loss of bladder control. She has a medical history of metastatic breast cancer. So with this history, what's the main worry that you have, what should be going off in your, what's the main thing that you need to be worried about? So, um she's got a history of me metastatic cancer and has got some, he's got back, she's got back pain and um some neurological symptoms. So the first worry is gonna be metastatic spinal cord compression, right. Um So M SCC can be caused by primary tumors. So there can be tumors of the central out of our system or uh bur team is tumors of the vertebrae or it can be caused by uh metastatic cancers. Er, they were potato divers in his and caused the collapse um and the compression of the um of the spinal cord. Now, in terms of the location of um M SCC is usually, it's more commonly um at the thoracic region, the lumbar and the cervical uh and it's just important to bear in mind. So, ok. Um what additional symptoms will you be seeing in a patient who has got um compression in the thoracic region than a patient who's got compression in the lumbar region? No. Yes. Yeah. I'm really glad you mentioned Ca Auana. So yeah, that can be um so in terms of like, well, the higher the level, the more muscles are gonna be affected, the more regions are gonna be affected. But um the spinal cord ends at L1 L2, right? That's the Conus medullaris. So if there is something compressing the spine at the thoracic level, you are gonna get upper motion urine symptoms as well as probably low motion urine. Um So when you examine the patient just need to be careful of that cos below L1 L2, that's when you have the um um low motor new ones, lower motor um nerves. And if there is compression there, you will get cardioquin nerve. But if it's higher than that, you may get essentially myelopathies and maybe even off American urine um lesion sym symptoms. So that's a video of um so it's not of SE M SCC caused by a metastatic breast cancer. It's actually caused by a glioblastoma. But the only good image that I could find and if you look at it here, so that's, I don't know if you can see my cursor, but that's the, that's solution. And, um, can anyone have a guess at calling the level at what level this lesion has occurred? Um, so if you just like, er, count di vertebrae, so at the top we, we see dens. So that's gonna tell us as C two, we have C three, C four, C five, C six, C seven. Um We don't have AC eight. So that's T one, T two and T three. So it's happening at the T three level. Um Yeah. And then in terms of presentation, so we talked about severe back pain that is, does not go away with painkillers. It's worse on movements, especially neck flexion. They've got weakness in the lower limbs, change in sensation, they can have off motor neurine lesions. So, um if it's in the thoracic region or, and so they may have hypotonia, brisk reflexes and um they may even have Cardi Guana Sy syndrome if it's compressing the um uh called equina, which is after the uh after now what to do when you suspect um malignant spinal cord compression. Can you go ahead help me? So, what, what should you do? I Yes. Yeah. Amazing. So, yes, you need to start him on high dose steroids. 16 mg IV stat, you need to inform the oncology team and uh the patient is going to need urgent MRI spine within the next 24 hours. And uh also think holistically the patient's gonna a, he's gonna need analgesia. And if they're in a lot of pain that they can't move, they're gonna be immobile, they're gonna need VT prophylaxis and um heads stockings. And also if they are immobile, if they can't go to the, to the commode, then they may, you may need to consider maybe like pads or any making it more accessible for them to go to the toilet. Now, after the MRI after within 24 hours of diagnosis, the patient's going to need either radiotherapy or surgical decompression. Um So the steroids will help to reduce the edema and alleviate the compression on the nerves and then the surgery will be more of a definitive decompression. Uh And it's paramount because early intervention is absolutely paramount for um neurological recovery. So that's why time is of the essence with M sec. So when you suspect it, you need to start the steroids. Um Yeah. Ok. So you've got some single best answer questions and some not single best answer questions. Um But I'm hoping you guys can um help me and engage with these questions. Um There are some easy questions and um some not so easy, but I'm sure you guys will breeze, will breeze through. Um Yeah. Right. First question. So this is the CT scan of a patient with colorectal cancer. Um Now based on the image, what stage is this likely to be? So we're starting with an easy question and you probably know which ones the answer. So just put it in the chat. Yeah. Yeah. So yeah, well done designer. It's stage four. No, no, not stage four. It's the uh option four. The T two N two M one is likely more likely to be the staging for this cancer. Um because there are plenty a numerous amount of um liver mets. Uh And the reason I use this question is just to remind you guys that colorectal cancer is staged with the TNM staging system. So the Duke stage is no longer used that much and TNM is more commonly used. Um So because there is metastasis, so if there is no metastasis, the M is zero, if there is metastasis, then M becomes one. So because they are met, then it's uh option four. All right. So, so we know there's a bowel cancer screening. Now, does anyone know which one, what the age group is? And how often it is performed, how often it is done? Mhm. Yes. So brilliant. So it's option three, age 6074 and every two years and as Amy correctly mentioned, it has been expanded to er, encompass 50 to 74 year olds and er, since 2021 or 2022 I'm not sure. And every year they're in um like introducing, er, inviting uh more people within the age group um to include 50 to 74. But for now, officially, it's still 60 to 74 and it's on every two years. So they get a kit in the mail um that they send off. Ok. Now, can you guys tell me what tumor marker is um associated with colorectal cancer? Yeah, brilliant. So, carcinoembryonic antigen is associated with colorectal cancer. Uh Option two C A 15-3. That's for breast cancer. Uh 90-9. That's a prostate 125 that's ovarian and uh A CG um can be associated with germ Saltor. Um OK. So we got another patient, 90 year old male presents with intense pain in his left hip. What is the most likely type of cancer causing this pain? And what pattern of bone metastases is typically associated with it? And you may be able to see it in this um radiograph as well. Ok. Yeah. So um an an elderly male patient with um bone pain back pain should be, you need to be wary of two things. So, myeloma and prostate cancer, right? Because these can cause uh bone mets uh as well as other malignancies, but they can be more common in like in elderly male patients. And uh when you do it uh plain radiograph, um you'll get more information in terms of the nature of the metastases. So myelomas tend to be osteolytic, right? So, you will get areas of hypodensity. Um but prostate uh mets, they are osteosclerotic. OK. So you can see areas of um hyper density, you may get areas of hyperdensity as well, but you will see some areas some hyperdense er foci. So you can see it in the um in the right femur, you can see the the hyperdense area and some other regions on the um um in Ilia. So just as a question, if someone has um osteolytic bone mets, what would you expect to see in their bone profile? So, what would you see? Um how would you expect their A LP and calcium levels to be? So, A LP will be, will be raised. So will the calcium cos it's osteolytic but in osteoblastic permits, the AP will be high cos there is high bone turnover but the calcium can be normal. So that's another thing that can differentiate between, between the two. OK. OK. What is the most common histological type of prostate cancer? Say squamous adeno neurocrine or transitional. The most common is adenocarcinoma. So if you think about it, prostate is a gland. So it's cancer, it's going to be cancer of glandular origin probably. Uh And adenocarcinoma is the most common uh histological type. The other options, they are also associated associated with prostate cancer. They can be findings uh histological findings in prostate cancer, but they are much more rare. Adenocarcinoma is the most prevalent histology. OK. So when we do a biopsy, then it is assessed and it gets a Gleason score. Right. Gleason grading now, which range indicates a high risk category for aggressive prostate cancer. Yeah. Right. So Gleason score is um made up of two numbers. So first number is shows the most prevalent histological type. And then the second number is the second most prevalent surgical type and it goes from three plus 3 to 5 plus five with the higher you go, the more aggressive. Um the more the less differentiated the tumor is and um the high graded half. So three plus 36 is the lowest and five plus 5, 10 is the highest and anything eight or higher is um can be categorized as a high risk. Um So yeah, 5.5 that's pretty aggressive. Now, what are three tools commonly used to evaluate the prognosis of prostate cancer? So we mentioned uh we have already mentioned one of them. What is the other two? Yeah, t of staging. Absolutely. Yeah. So when you do act cap, um that'll tell you more about the staging. So yeah, staging and uh the last one is P SA and the other one is um that applies to all cancers is the performance status. So, um performance status goes from 0 to 50 being patients fully active and five being the patient's dead. So the higher goes, the worse the patient's performance is so you can get T staging. Gleason grading P SA. And on top of that, they can include the patient performance status. Now, different treatments for prostate cancer just gonna walk through. So there is active surveillance. So if it's a low grade tumor, you can just monitor it. So if it's got a local tumor, it's has got a very low Gleason score like Gleason score of six. The PSA is less than 10. It's not too high, you just monitor the patient. Um The other one is watchful waiting. So watchful waiting. Does anyone know the difference between active surveillance and watchful waiting? No sense. So active surveillance is for a low grade tumor in a patient who's can be pretty um healthy, you know, because they have a good performance status. But if the patient is quite small and low grade, then you can just monitor it. It may not even progress to becoming something more serious. What you waiting is done for um more um less with patients, patients with multiple comorbidities and the lower performance status and is essentially it can be a high grade tumor, it can be an aggressive tumor, but the patient would not benefit from treatment. So essentially just watching them watching for any symptoms and then treat the symptoms. Um So you do watch for waiting for patients who are not very fit and they may have multiple comorbidities. There is radical prostatectomy, there is a radical radiotherapy and then on top of that, um there is um if it's malignant prostate cancer can do castration. So it can be a chemical castration with um gonadotrophin releasing hormone agonists or antiandrogens. Or it can be a surgical castration by bilateral orchidectomy. But yeah. Ok. So we talked about PSA and we know that there is no screening currently going for uh prostate cancer. But I thought this would be a good opportunity to revise some concept about screening. So, does anyone know what lead time bias is? So lead time bias is when the patient is diagnosed earlier than they would have if there was any screening, but the patient isn't actually surviving any longer than they would have. Um So in this example, then the screening is making a false appearance and the patient is surviving longer, but that's not really the case. So essentially awareness of disease is making a false um appearance that the patient is living longer. Now with lead time bias, there is another concept which is lended time bias. And that's when um essentially it describes a concept that screen tools are more able to pick up slowly growing um diseases that they have a long phase of being asymptomatic, you know. Um so when there is screening, you pick up both slow growing and fast growing um conditions, but if there was no screening, they would only be picked up if they are symptomatic, right? So because of that, there will be a perceived survival time difference, cos more patients with say the cancer are living longer. But the only difference with um situation without the screening is that those patients with slow growing um cancers that were just not detected. So I don't know if that's making sense, but length unbias essentially, it makes this false appearance of the patients are um that the screening is helping with the survival. Um Yeah. Ok. Uh So we're going into our next case um just before moving on. Does that make sense? The lead time and let time bias concepts and the difference between them? Does that make sense? No. Yeah, I hope, I hope that was helpful. Ok. So next case, we've got a female patient, 60 year old, female patient attends the breast clinic with a painless lump in her left breast and based on the mammogram, can you guess the type of this breast cancer? I know this may be a bit, a bit of a tough question but um just have a go. Yeah. So um will be name me. It is invasive ductal carcinoma. Um So if you go through the um the options. So lobular carcinomas both invasive and um ductal in er sorry, in situ ones, they are not radio picked, they're not really picked up on mammograms. They are usually found incidentally on biopsy. Um and ductal carcinoma in situ, you'll see foci of calcification, not a big um big lump usually. And invasive ductal carcinoma is the most common type of um breast cancer. Um it's also known as a nonspecial type. So all of that included and the image, it makes it more likely for it to be an invasive ductal carcinoma. And we can see the image that's a craniocaudal mammogram and it's showing a big area of hyper dense area. Um Yeah. And if we do an we can do an ultrasound to um for more information and you can see that it is firstly, it is irregular. Secondly, it is hypoechoic. So it's darker, right? So that's telling us that this mass is more solid than the tissue around it because solid, more dense um tissues, they are high, they are less um echogenic. So you get hypo echoic regions and also you can see some uh folk kind of hyper of calcification, see those white terriers. So um yeah. So that's all all this information is in line with an invasive ductal carcinoma. Now, next question, we've got a 50 year old female who attends the breast clinic for her routine um appointment via routine appointment at the breast um via screening. Ok. So going back to the history was no lump. And on the mammogram, you can see that there are some foci of calcification, some isolated foci. So that makes it more likely for it to be ductal carcinoma in situ cos they're usually picked up cos these are precancerous states, precancerous conditions. So they're usually picked up during the screening. These are actually the ones that are picked up during screening. And um also to note these um findings in the mammogram, they usually underestimate the extent of the disease. So the patient may need a, an MRI or um an ultrasound to further investigate the extent of um DCIS. Ok. So I think this is the last case. We've got a few more questions for this one. So a 58 year old woman with history of breast cancer who was treated five years ago, arrives at the emergency department, complaining of headaches, confusion and recent seizures. So we suspect brain meds, right? What is the most appropriate initial interven intervention? So, going back to the question, history of cancer headache, that is it tends to be like constant um and uh neurological symptoms. So they all should, you know, make you think about brain meds. And uh the the first thing to do in brain meds is to reduce the edema that's causing these neurological symptoms. And that's done by high dose steroids. Cos you need to lower the the the um vasogenic edema in the brain. So after that again, depends on where the cancer is. They can undergo. The patient can undergo uh whole brain radiotherapy or if the cancer is more peripheral, they may be eligible for surgical resection. Um but that's usually less likely because the cancer. If it's a metastasis, it can be quite deep in the brain tissue and not accessible. But the first thing to do is the steroid. Um So, next question, next question is um about some of the risk factors for breast cancer. So, we've got a female age, family history or previous history. BRCA one and two genes. Um So estrogen exposure, now that can be um endogenous estrogen exposure. So, early menarche, late menopause or exogenous like C OCP and uh combined. Um H RT not breastfeeding, not a parity and obesity are also some of the other risk factors. Uh So, in this patient, um she's postmenopausal, uh which of the following hormone therapies are commonly recommended for post menopausal women with uh hormone receptor positive breast cancer. Ok. That's it. Ok. Mhm Yeah. The correct answer is um an ASO. So in postmenopausal women, the first line is an aromatase inhibitor. Co we need to um kind of lower that estrogen, right. And if they're already menopausal, they're not producing estrogen in the ovaries. The main source of estrogen is in the peripheral fat tissue where um the aromatase enzymes are converting androgens to estrogen. So, by blocking that we'll be able to reduce that estrogen more effectively. So, in post menopausal women, anastrozole is more of a first line. But in permenopausal tamoxifen is the first line. So, tamoxifen is ac is a selective estrogen receptor modulator. So it blocks estrogen in the um in the breast as estrogen receptors in breast but is osteoprotective. So the point cause osteoporosis, but as a negative effect, it can cause um can increase risk of endometrial cancer. Ok. That's a caveat. Uh, like breast cancer, screening, what age group, um, are qualified for screening? And how often is it performed? Is it 50 to 70 every two years, 50 to 70 every three years, 40 to 70 every two years or 40 to 70 every three years. Yeah. Amazing. So, um, it's 50 to 70. Uh, so people, women age 50 to 70 they will receive, uh, an invitation er, every three years to attend a breast clinic. Now that can start a little earlier um as well. They can start from when they are 47. Um uh but the overall is 5070 in patients over 70 they may not receive the invitation but they can still self refer themselves to the breast clinic if they uh if they want, but they, they don't get the mutation. Yeah. Oh yeah, that's it. Um So thank you very much for listening. Um Hope that was useful. Um If you have any questions, feel free to put them in the chat. Um and we also have a feedback form so that if you guys could kindly foot it out, then I would be able to give you guys the slides. Yeah. Thank you again, everyone. Um After you've f filled out the feedback form. Um Yeah, you're happy to leave. Um We'll be putting the slides up on our account here on um Leicester Radiology Society. Count on metal. So, you'll be able to access them here if you want. Yeah. Um.